Family and Medical Leave Act of 1993, As Amended

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form WH-382 Designation Notice (Family and Medical Leave Act)	Form and Instruction	Modified	Available
Form WH-381 Notice of Eligibility and Rights & Responsibilities (Family and Medical Leave Act)	Form and Instruction	Modified	Available
Form WH-381 Notice of Eligibility and Rights & Responsibilities (Family and Medical Leave Act)	Form and Instruction	Modified	Available
Form WH-382 Designation Notice (Family and Medical Leave Act)	Form and Instruction	Modified	Available
Form WH-382 Designation Notice (Family and Medical Leave Act)	Form and Instruction	Modified	Repair queued
Form WH-381 Notice of Eligibility and Rights & Responsibilities (Family and Medical Leave Act)	Form and Instruction	Modified	Repair queued
Form WH-385-V Certification for Serious Injury or Illness of a Veteran for Military Caregiver Leave (Family and Medical Leave Act)	Form and Instruction	Modified	Available
Form WH-380-F Certification of Health Care Provider for Family Member’s Serious Health Condition (Family and Medical Leave Act)	Form and Instruction	Modified	Repair queued
Form WH-380-E Certification of Health Care Provider for Employee’s Serious Health Condition (Family and Medical Leave Act)	Form and Instruction	Modified	Available
Form WH-385 Certification for Serious Injury or Illness of a Current Servicemember -for Military Family Leave (Family and Medical Leave Act)	Form and Instruction	Modified	Available
Form WH-384 Certification of Qualifying Exigency For Military Family Leave (Family and Medical Leave Act)	Form and Instruction	Modified	Available
1235-0003 FMLA PRA supplemental satement 2018 final draft 4-13-2018.docx	Supporting Statement A	Uploaded 2018-04-13	Available
Federal Register Notice FMLA PRA revision 82 FR 48850.pdf	Supplementary Document	Uploaded 2018-04-06	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
187163	Notice to Employee of Change of 12-Month Period for Determining Entitlement (Federal)		Modified
187079	Notice to Employee of Pending Cancellation of Health Benefits (Federal)		Modified
187078	Notice to Employee of FMLA Designation (Federal)	Form and Instruction	Modified	Designation Notice (Family and Medical Leave Act)
187073	Key Employee Notification (Federal)		Modified
186957	Notice to Employee of Change of 12-Month Period for Determining Entitlement (State, local, tribal)		Modified
186955	Notice to Employee of FMLA Eligibilty and Rights & Responsibilities (Federal)	Form and Instruction	Modified	Notice of Eligibility and Rights & Responsibilities (Family and Medical Leave Act)
186913	Notice to Employee of FMLA Eligibility and Rights & Responsibilities (State, local, tribal)	Form and Instruction	Modified	Notice of Eligibility and Rights & Responsibilities (Family and Medical Leave Act)
186900	Notice to Employee of Pending Cancellation of Health Benefits (State, local, tribal)		Modified
186899	Notice to Employee of FMLA Designation (State, local, tribal)	Form and Instruction	Modified	Designation Notice (Family and Medical Leave Act)
186898	General FMLA Recordkeeping (Federal)		Modified
186891	Key Employee Notification (State, local, tribal)		Modified
186890	General FMLA Recordkeeping (State, local, tribal)		Modified
182234	Notice to Employee of Pending Cancellation of Health Benefits (Private Sector)		Modified
182233	Documenting Family Relationship		Modified
182083	Periodic Employee Status Report		Modified
182081	Notice to Employee of FMLA Designation (Private Sector)	Form and Instruction	Modified	Designation Notice (Family and Medical Leave Act)
178656	General FMLA Recordkeeping (Private Sector)		Modified
178655	Key Employee Notification (Private Sector)		Modified
178653	Notice to Employee of Change of 12-Month Period for Determining Entitlement (Private Sector)		Modified
178607	Employee's Notice of Need for FMLA Leave		Modified
178568	Notice to Employee of FMLA Eligibility and Rights & Responsibilities (Private Sector)	Form and Instruction	Modified	Notice of Eligibility and Rights & Responsibilities (Family and Medical Leave Act)
13897	Employee Certifications (Serious Health Condition, Recertification, Fitness-for-Duty; Call to Military Active Duty; Qualifying Exigency Due o Call to Military Active Duty; Servicemember Illness/Injuy	Form and Instruction	Modified	Certification for Serious Injury or Illness of a Veteran for Military Caregiver Leave (Family and Medical Leave Act)
13897	Employee Certifications (Serious Health Condition, Recertification, Fitness-for-Duty; Call to Military Active Duty; Qualifying Exigency Due o Call to Military Active Duty; Servicemember Illness/Injuy	Form and Instruction	Modified	Certification of Health Care Provider for Family Member’s Serious Health Condition (Family and Medical Leave Act)
13897	Employee Certifications (Serious Health Condition, Recertification, Fitness-for-Duty; Call to Military Active Duty; Qualifying Exigency Due o Call to Military Active Duty; Servicemember Illness/Injuy	Form and Instruction	Modified	Certification of Health Care Provider for Employee’s Serious Health Condition (Family and Medical Leave Act)
13897	Employee Certifications (Serious Health Condition, Recertification, Fitness-for-Duty; Call to Military Active Duty; Qualifying Exigency Due o Call to Military Active Duty; Servicemember Illness/Injuy	Form and Instruction	Modified	Certification for Serious Injury or Illness of a Current Servicemember -for Military Family Leave (Family and Medical Leave Act)
13897	Employee Certifications (Serious Health Condition, Recertification, Fitness-for-Duty; Call to Military Active Duty; Qualifying Exigency Due o Call to Military Active Duty; Servicemember Illness/Injuy	Form and Instruction	Modified	Certification of Qualifying Exigency For Military Family Leave (Family and Medical Leave Act)

ICR Details

OMB Control No: 1235-0003	ICR Reference No: 201711-1235-001
Status: Historical Active	Previous ICR Reference No: 201507-1235-001
Agency/Subagency: DOL/WHD	Agency Tracking No:
Title: Family and Medical Leave Act of 1993, As Amended
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/09/2018
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/20/2018
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2021	36 Months From Approved	08/31/2018
Responses	79,357,763	0	82,371,724
Time Burden (Hours)	8,973,607	0	9,313,503
Cost Burden (Dollars)	193,532,818	0	184,932,912

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Abstract: This ICR implements statutory notice and certification provisions and to assist employees and employers in meeting their FMLA third-party notification obligations as required by the Family and Medical Leave Act of 1993 (FMLA). The subject recordkeeping requirements are necessary in order for the DOL to carry out its statutory obligation under FMLA section 106 to investigate and ensure employer compliance. 29 U.S.C. § 2616.

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Authorizing Statute(s): US Code: 29 USC 2616 Name of Law: Family and Medical Leave Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 48850	10/20/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 17566	04/20/2018
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 22

table that charts list of burden

IC Title	Form No.	Form Name
Documenting Family Relationship
Employee Certifications (Serious Health Condition, Recertification, Fitness-for-Duty; Call to Military Active Duty; Qualifying Exigency Due o Call to Military Active Duty; Servicemember Illness/Injuy	WH-385, WH-384, WH-380-F, WH-385-V, WH-380-E	Certification of Qualifying Exigency For Military Family Leave (Family and Medical Leave Act) ,   Certification for Serious Injury or Illness of a Current Servicemember -for Military Family Leave (Family and Medical Leave Act) ,   Certification of Health Care Provider for Employee’s Serious Health Condition (Family and Medical Leave Act) ,   Certification of Health Care Provider for Family Member’s Serious Health Condition (Family and Medical Leave Act) ,   Certification for Serious Injury or Illness of a Veteran for Military Caregiver Leave (Family and Medical Leave Act)
Employee's Notice of Need for FMLA Leave
General FMLA Recordkeeping (State, local, tribal)
General FMLA Recordkeeping (Federal)
General FMLA Recordkeeping (Private Sector)
Key Employee Notification (Federal)
Key Employee Notification (Private Sector)
Key Employee Notification (State, local, tribal)
Notice to Employee of Change of 12-Month Period for Determining Entitlement (Federal)
Notice to Employee of Change of 12-Month Period for Determining Entitlement (Private Sector)
Notice to Employee of Change of 12-Month Period for Determining Entitlement (State, local, tribal)
Notice to Employee of FMLA Designation (Federal)	WH-382	Designation Notice (Family and Medical Leave Act)
Notice to Employee of FMLA Designation (Private Sector)	WH-382	Designation Notice (Family and Medical Leave Act)
Notice to Employee of FMLA Designation (State, local, tribal)	WH-382	Designation Notice (Family and Medical Leave Act)
Notice to Employee of FMLA Eligibility and Rights & Responsibilities (Private Sector)	WH-381	Notice of Eligibility and Rights & Responsibilities (Family and Medical Leave Act)
Notice to Employee of FMLA Eligibility and Rights & Responsibilities (State, local, tribal)	WH-381	Notice of Eligibility and Rights & Responsibilities (Family and Medical Leave Act)
Notice to Employee of FMLA Eligibilty and Rights & Responsibilities (Federal)	WH-381	Notice of Eligibility and Rights & Responsibilities (Family and Medical Leave Act)
Notice to Employee of Pending Cancellation of Health Benefits (Federal)
Notice to Employee of Pending Cancellation of Health Benefits (Private Sector)
Notice to Employee of Pending Cancellation of Health Benefits (State, local, tribal)
Periodic Employee Status Report

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	79,357,763	82,371,724	0	0	-3,013,961	0
Annual Time Burden (Hours)	8,973,607	9,313,503	0	0	-339,896	0
Annual Cost Burden (Dollars)	193,532,818	184,932,912	0	0	8,599,906	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: There is a slight decrease in responses and burden hours due to a decrease in the estimated number of FMLA eligible workers. The decrease in estimated burden hours produced a slight decrease in total burden cost. There was a modest increase in total operations and maintenance cost which is attributed to a $5.73 increase in the health care provider hourly wage rate applied to the slight reduction in health care provider burden hours. Lastly, Federal cost decreased slightly because printing costs were applied to only half of the total pages calculation to capture printing on the front and back of each page.

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Annual Cost to Federal Government: $690,135

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 04/20/2018

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