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

Family and Medical Leave Act of 1993, As Amended

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.