FMLA Comment Card Supplemental Document

Request for Approval under the “DOL Departmental Generic Clearance for the Collection of Routine Customer Feedback”

(OMB Control Number: 1225-0088)

TITLE OF INFORMATION COLLECTION: FMLA Forms Comment Card

PURPOSE:

The Wage and Hour Division (WHD) administers the Family and Medical Leave Act of 1993 (FMLA), 29 U.S.C. § 2601, et seq., requires private sector employers who employ 50 or more employees, all public and private elementary schools, and all public agencies to provide up to 12 weeks of unpaid, job-protected leave during any 12-month period to eligible employees for certain family and medical reasons and up to 26 workweeks of unpaid, job protected leave during a single 12-month period to care for a covered servicemember with a serious injury or illness who is the spouse, son, daughter, parent, or next of kin to the employee. FMLA section 404 requires the Secretary to prescribe such regulations as necessary to enforce this Act. 29 U.S.C. § 2654. The FMLA/OLS Branch of the WHD provides optional-use forms for employers, employees and Health Care Providers to assist in proper and efficient administration of the FMLA.

The WHD will participate in the Disability Management Employer Coalition (DMEC) 2018 DMEC FMLA/ADA Employer Compliance Conference April 30-May 3, 2018. The DMEC is a national non-profit professional organization with a membership of 9,500 employer representatives working in the field of absence management for the workplace. The WHD will participate in the conference and host a discussion with respect to the current FMLA forms, their functionality, and solicit feedback from participants about any suggestions with respect to making the optional-use forms easier to use, easier to understand, and easier to complete. WHD performs its outreach events with an eye toward evaluating the usefulness of the optional-use forms and their role in conveying employer rights and responsibilities, employee rights and responsibilities and ease of administration of the FMLA. Examining WHD’s program quality and responsiveness to clients furthers the purpose of the Government Performance and Results Act (31 U.S.C. § 1115). The information collection will be used to evaluate WHD’s customer service and to consider making improvements in the optional-use FMLA forms.

The proposed information collection instrument is attached for review.

DESCRIPTION OF RESPONDENTS:

The WHD will participate in the Disability Management Employer Coalition (DMEC) 2018 DMEC FMLA/ADA Employer Compliance Conference April 30-May 3, 2018. The DMEC is a national non-profit professional organization with a membership of 9,500 employer representatives working in the field of absence management for the workplace. Approximately 300 of the attendees of the conference may participate in the outreach regarding the optional-use FMLA forms.

TYPE OF COLLECTION: (Check one)

[X ] Customer Comment Card/Complaint Form [ ] Customer Satisfaction Survey

[ ] Usability Testing (e.g., Website or Software [ ] Small Discussion Group

[] Focus Group [ ] Other: ______________________

CERTIFICATION:

I certify the following to be true:

1. The collection is voluntary.

2. The collection is low-burden for respondents and low-cost for the Federal Government.

3. The collection is non-controversial and does not raise issues of concern to other federal agencies.

4. The results are not intended to be disseminated to the public.

5. Information gathered will not be used for the purpose of substantially informing influential policy decisions.

6. The collection is targeted to the solicitation of opinions from respondents who have experience with the program or may have experience with the program in the future.

Name:_________Robert Waterman____

To assist review, please provide answers to the following question:

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? [ ] Yes [X ] No

2. If Yes, is the information that will be collected included in records that are subject to the Privacy Act of 1974? [ ] Yes [ ] No

3. If Applicable, has a System or Records Notice been published? [ ] Yes [ ] No

Gifts or Payments:

Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants? [ ] Yes [ X ] No

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden
Employer representatives	300	10	50
Totals	300	10	50

FEDERAL COST: The estimated annual cost to the Federal government is __$5655 (rounded)

If you are conducting a focus group, survey, or plan to employ statistical methods, please provide answers to the following questions:

The selection of your targeted respondents

1. Do you have a customer list or something similar that defines the universe of potential respondents and do you have a sampling plan for selecting from this universe? [ ] Yes [ X] No

If the answer is yes, please provide a description of both below (or attach the sampling plan)? If the answer is no, please provide a description of how you plan to identify your potential group of respondents and how you will select them?

Administration of the Instrument

1. How will you collect the information? (Check all that apply)

[ ] Web-based or other forms of Social Media

[ ] Telephone

[X ] In-person

[ ] Mail

[ ] Other, Explain

2. Will interviewers or facilitators be used? [X ] Yes [ ] No

One WHD National Office Staff member will facilitate discussion.

Please make sure that all instruments, instructions, and scripts are submitted with the request.

Instructions for completing Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback”

TITLE OF INFORMATION COLLECTION: Provide the name of the collection that is the subject of the request. (e.g. Comment card for soliciting feedback on xxxx)

PURPOSE: Provide a brief description of the purpose of this collection and how it will be used. If this is part of a larger study or effort, please include this in your explanation.

DESCRIPTION OF RESPONDENTS: Provide a brief description of the targeted group or groups for this collection of information. These groups must have experience with the program.

TYPE OF COLLECTION: Check one box. If you are requesting approval of other instruments under the generic, you must complete a form for each instrument.

CERTIFICATION: Please read the certification carefully. If you incorrectly certify, the collection will be returned as improperly submitted or it will be disapproved.

Personally Identifiable Information: Provide answers to the questions.

Gifts or Payments: If you answer yes to the question, please describe the incentive and provide a justification for the amount.

BURDEN HOURS:

Category of Respondents: Identify who you expect the respondents to be in terms of the following categories: (1) Individuals or Households;(2) Private Sector; (3) State, local, or tribal governments; or (4) Federal Government. Only one type of respondent can be selected.

No. of Respondents: Provide an estimate of the Number of respondents.

Participation Time: Provide an estimate of the amount of time required for a respondent to participate (e.g. fill out a survey or participate in a focus group)

Burden: Provide the Annual burden hours: Multiply the Number of responses and the participation time and divide by 60.

FEDERAL COST: Provide an estimate of the annual cost to the Federal government.

If you are conducting a focus group, survey, or plan to employ statistical methods, please provide answers to the following questions:

The selection of your targeted respondents. Please provide a description of how you plan to identify your potential group of respondents and how you will select them. If the answer is yes, to the first question, you may provide the sampling plan in an attachment.

Administration of the Instrument: Identify how the information will be collected. More than one box may be checked. Indicate whether there will be interviewers (e.g. for surveys) or facilitators (e.g., for focus groups) used.

Please make sure that all instruments, instructions, and scripts are submitted with the request.

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