Employment Information Form

Forms and Documents

Document Name	Status
Form WH-3-Sp Employment Information Form Form and Instruction	Modified
1235-0021 Justification for non-material change 20200514.docx Justification for No Material/Nonsubstantive Change	2020-05-15
justification for non-material change 1235-0021.docx Justification for No Material/Nonsubstantive Change	2020-03-29
FR 60 day notice (correction) 20180514.pdf Supplementary Document	2019-05-21
FR public. 20180502.pdf Supplementary Document	2019-05-21
PAID cert. items 2018.pdf Supplementary Document	2019-05-21
FR 60-day 1235-0021 20190312.pdf Supplementary Document	2019-05-21
opm salary table 2019.pdf Supplementary Document	2019-05-21
empsit April 2019.pdf Supplementary Document	2019-05-21
Supporting Statement 1235-0021 v1.3 (2021-07-04).docx Supporting Statement A	2021-07-04

IC Document Collections

IC ID	Document Title	Status
236191	PAID Instruction	Removed
13616	Employment Information Form Form and Instruction	Modified

ICR Details

OMB Control No: 1235-0021	ICR Reference No: 202105-1235-003
Status: Received in OIRA	Previous ICR Reference No: 202005-1235-001
Agency/Subagency: DOL/WHD	Agency Tracking No:
Title: Employment Information Form
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 07/22/2021

	Requested	Previously Approved
Expiration Date	11/30/2022	11/30/2022
Responses	38,240	38,125
Time Burden (Hours)	12,747	12,771
Cost Burden (Dollars)	0	2

---

Abstract: WHD staff use Form WH-3 as a guide for obtaining information complainants (e.g., current and former employees, unions, and competitor employers) voluntarily provide about alleged violations of agency-administered labor standards. Complainants generally provide the information requested on the form to WHD staff over the telephone or in person. WHD staff use the information to determine whether the agency has jurisdiction to investigate the alleged violation(s). When the WHD schedules a complaint-based investigation, the agency makes the completed Form WH-3 part of the investigation case file. Where the information provided does not support a potential WHD enforcement action, complainants are advised and referred to the appropriate agency for further assistance.

---

Authorizing Statute(s): US Code: 29 USC 2616(a) Name of Law: Family and Medical Leave Act
   US Code: 29 USC 1862(a) Name of Law: Migrant and Seasonal Agricultural Worker Protection Act
   US Code: 15 USC 1676 Name of Law: Consumer Credit Protection Act
   US Code: 40 USC 3141 Name of Law: Davis Bacon Act
   US Code: 41 USC 38 Name of Law: Walsh-Healey Public Contracts Act
   US Code: 41 USC 353(a) Name of Law: McNamara-O'Hara Service Contract Act
   US Code: 8 USC 1188(g) Name of Law: Immigration and Nationality Act
   EO: EO 13658 Name/Subject of EO: Establishing a Minimum Wage for Contractors
   EO: EO 13706 Name/Subject of EO: Establishing Paid Sick Leave for Contractors
   US Code: 29 USC 211(a) Name of Law: Fair Labor Standards Act
   PL: Pub.L. 116 - 127 110 Name of Law: Families First Coronavirus Response Act
   PL: Pub.L. 116 - 127 5105 Name of Law: Families First Coronavirus Response Act
   US Code: 19 USC 4532 Name of Law: United States-Mexico-Canada Agreement Implementation Act
   US Code: 29 USC 2004(a)(3) Name of Law: Employee Polygraph Protection Act
   EO: EO 14026 Name/Subject of EO: Increasing the Minimum Wage for Federal Contractors
  

Citations for New Statutory Requirements: PL: Pub.L. 116 - 127 5105 Name of Law: Families First Coronavirus Response Act
PL: Pub.L. 116 - 127 110 Name of Law: Families First Coronavirus Response Act

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
1235-AA41	Proposed rulemaking	86 FR 38816	07/22/2021

---

Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Employment Information Form	WH-3, WH-3-Sp	Employment Information Form Spanish ,   Employment Information Form
PAID	WH-1527	PAID certificate

---

ICR Summary of Burden

	Total Request	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	38,240	38,125	0	-50	165	0
Annual Time Burden (Hours)	12,747	12,771	0	-79	55	0
Annual Cost Burden (Dollars)	0	2	0	-2	0	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The PAID pilot program has been discontinued and is being removed from this IC. A slight increase in complaints due to EO 14026.

---

Annual Cost to Federal Government: $737,981

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? No

---

Common Form ICR:  No

---

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: 07/22/2021

---