The Family and Medical Leave Act of 1993, As Amended

ICR 202302-1235-002

OMB: 1235-0003

Federal Form Document

⚠️ Notice: This information collection may be outdated.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

Forms and Documents

Document Name	Status
Form WH-382 Notice to Employee of FMLA Designation (Federal) Form and Instruction	Unchanged
Form WH-382 Notice to Employee of FMLA Designation (Federal) Form and Instruction	Unchanged
Form WH-381 Notice to Employee of FMLA Eligibilty and Rights & Responsibilities (Federal) Form and Instruction	Unchanged
Form WH-381 Notice to Employee of FMLA Eligibilty and Rights & Responsibilities (Federal) Form and Instruction	Unchanged
Form WH-381 Notice to Employee of FMLA Eligibility and Rights & Responsibilities (State, local, tribal) Form and Instruction	Unchanged
Form WH-381 Notice to Employee of FMLA Eligibility and Rights & Responsibilities (State, local, tribal) Form and Instruction	Unchanged
Form WH-382 Notice to Employee of FMLA Designation (State, local, tribal) Form and Instruction	Unchanged
Form WH-382 Notice to Employee of FMLA Designation (State, local, tribal) Form and Instruction	Unchanged
Form WH-382 Notice to Employee of FMLA Designation (Private Sector) Form and Instruction	Unchanged
Form WH-382 Notice to Employee of FMLA Designation (Private Sector) Form and Instruction	Unchanged
Form WH-381 Notice to Employee of FMLA Eligibility and Rights & Responsibilities (Private Sector) Form and Instruction	Unchanged
Form WH-381 Notice to Employee of FMLA Eligibility and Rights & Responsibilities (Private Sector) Form and Instruction	Unchanged
Form WH-385 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
Form WH-385 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
Justification for non-material change OCIO comment 2.27.23.docx Justification for No Material/Nonsubstantive Change	2023-02-27
Justification for non-material change OCIO comment 2.27.23.docx Justification for No Material/Nonsubstantive Change	2023-02-27
ss1235-0003 20200225.docx Supporting Statement A	2020-02-25
ss1235-0003 20200225.docx Supporting Statement A	2020-02-25

IC Document Collections

IC ID	Document Title	Status
187163	Notice to Employee of Change of 12-Month Period for Determining Entitlement (Federal)	Unchanged
187079	Notice to Employee of Pending Cancellation of Health Benefits (Federal)	Unchanged
187078	Notice to Employee of FMLA Designation (Federal) Form and Instruction	Unchanged
187078	Notice to Employee of FMLA Designation (Federal) Form and Instruction	Unchanged
187073	Key Employee Notification (Federal)	Unchanged
186957	Notice to Employee of Change of 12-Month Period for Determining Entitlement (State, local, tribal)	Unchanged
186955	Notice to Employee of FMLA Eligibilty and Rights & Responsibilities (Federal) Form and Instruction	Unchanged
186955	Notice to Employee of FMLA Eligibilty and Rights & Responsibilities (Federal) Form and Instruction	Unchanged
186913	Notice to Employee of FMLA Eligibility and Rights & Responsibilities (State, local, tribal) Form and Instruction	Unchanged
186913	Notice to Employee of FMLA Eligibility and Rights & Responsibilities (State, local, tribal) Form and Instruction	Unchanged
186900	Notice to Employee of Pending Cancellation of Health Benefits (State, local, tribal)	Unchanged
186899	Notice to Employee of FMLA Designation (State, local, tribal) Form and Instruction	Unchanged
186899	Notice to Employee of FMLA Designation (State, local, tribal) Form and Instruction	Unchanged
186898	General FMLA Recordkeeping (Federal)	Unchanged
186891	Key Employee Notification (State, local, tribal)	Unchanged
186890	General FMLA Recordkeeping (State, local, tribal)	Unchanged
182234	Notice to Employee of Pending Cancellation of Health Benefits (Private Sector)	Unchanged
182233	Documenting Family Relationship	Unchanged
182083	Periodic Employee Status Report	Unchanged
182081	Notice to Employee of FMLA Designation (Private Sector) Form and Instruction	Unchanged
182081	Notice to Employee of FMLA Designation (Private Sector) Form and Instruction	Unchanged
178656	General FMLA Recordkeeping (Private Sector)	Unchanged
178655	Key Employee Notification (Private Sector)	Unchanged
178653	Notice to Employee of Change of 12-Month Period for Determining Entitlement (Private Sector)	Unchanged
178607	Employee's Notice of Need for FMLA Leave	Unchanged
178568	Notice to Employee of FMLA Eligibility and Rights & Responsibilities (Private Sector) Form and Instruction	Unchanged
178568	Notice to Employee of FMLA Eligibility and Rights & Responsibilities (Private Sector) Form and Instruction	Unchanged
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
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

ICR Details