Information Collection

Notice to Employee of FMLA Eligibility and Rights & Responsibilities (State, local, tribal)

IC 186913 under ICR 201711-1235-001 · OMB 1235-0003.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1235-0003 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form WH-381 Notice to Employee of FMLA Eligibility and Rights & Responsibilities (State, local, tribal)	Form and Instruction
WH-381 Notice of Eligibility and Rights & Responsibilities (Fam WH-381.pdf www.dol.gov/whd/forms/WH-381.pdf	Form and Instruction

IC Title:

Notice to Employee of FMLA Eligibility and Rights & Responsibilities (State, local, tribal)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 29 CFR 825.300(b), (c)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	WH-381	Notice of Eligibility and Rights & Responsibilities (Family and Medical Leave Act)	WH-381.pdf	https://www.dol.gov/whd/forms/WH-381.pdf	Yes	No	Fillable Printable

Line of Business: Workforce Management

Subfunction: Labor Rights Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 101,731

Number of Respondents for Small Entity: 70,488

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	4,054,513	-144,285	4,198,798
Annual IC Time Burden (Hours)	675,752	-24,048	699,800
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.