The 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 Notice to Employee of FMLA Designation (Federal)	Form and Instruction	Modified	Available
Form WH-382 Notice to Employee of FMLA Designation (Federal)	Form and Instruction	Modified	Repair queued
Form WH-381 Notice to Employee of FMLA Eligibilty and Rights & Responsibilities (Federal)	Form and Instruction	Modified	Available
Form WH-381 Notice to Employee of FMLA Eligibilty and Rights & Responsibilities (Federal)	Form and Instruction	Modified	Repair queued
Form WH-381 Notice to Employee of FMLA Eligibility and Rights & Responsibilities (State, local, tribal)	Form and Instruction	Modified	Available
Form WH-381 Notice to Employee of FMLA Eligibility and Rights & Responsibilities (State, local, tribal)	Form and Instruction	Modified	Repair queued
Form WH-382 Notice to Employee of FMLA Designation (State, local, tribal)	Form and Instruction	Modified	Available
Form WH-382 Notice to Employee of FMLA Designation (State, local, tribal)	Form and Instruction	Modified	Repair queued
Form WH-382 Notice to Employee of FMLA Designation (Private Sector)	Form and Instruction	Modified	Available
Form WH-382 Notice to Employee of FMLA Designation (Private Sector)	Form and Instruction	Modified	Repair queued
Form WH-381 Notice to Employee of FMLA Eligibility and Rights & Responsibilities (Private Sector)	Form and Instruction	Unchanged	Available
Form WH-381 Notice to Employee of FMLA Eligibility and Rights & Responsibilities (Private Sector)	Form and Instruction	Unchanged	Repair queued
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	Available
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	Repair queued
Justification for Nonsubstantive Change 1235-0003 (2023-06-02).docx	Justification for No Material/Nonsubstantive Change	Uploaded 2023-06-02	Available
Justification for Nonsubstantive Change 1235-0003 (2023-06-02).docx	Justification for No Material/Nonsubstantive Change	Uploaded 2023-06-02	Repair queued
60-day FR notice 2022-11-09.pdf	Supplementary Document	Uploaded 2023-04-13	Available
60-day FR notice 2022-11-09.pdf	Supplementary Document	Uploaded 2023-04-13	Repair queued
Supporting Statement 1235-0003 (2023-06-06).docx	Supporting Statement A	Uploaded 2023-06-06	Available
Supporting Statement 1235-0003 (2023-06-06).docx	Supporting Statement A	Uploaded 2023-06-06	Repair queued

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)		Unchanged
187079	Notice to Employee of Pending Cancellation of Health Benefits (Federal)		Unchanged
187078	Notice to Employee of FMLA Designation (Federal)	Form and Instruction	Modified
187078	Notice to Employee of FMLA Designation (Federal)	Form and Instruction	Modified
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	Modified
186955	Notice to Employee of FMLA Eligibilty and Rights & Responsibilities (Federal)	Form and Instruction	Modified
186913	Notice to Employee of FMLA Eligibility and Rights & Responsibilities (State, local, tribal)	Form and Instruction	Modified
186913	Notice to Employee of FMLA Eligibility and Rights & Responsibilities (State, local, tribal)	Form and Instruction	Modified
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	Modified
186899	Notice to Employee of FMLA Designation (State, local, tribal)	Form and Instruction	Modified
186898	General FMLA Recordkeeping (Federal)		Modified
186891	Key Employee Notification (State, local, tribal)		Unchanged
186890	General FMLA Recordkeeping (State, local, tribal)		Modified
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	Modified
182081	Notice to Employee of FMLA Designation (Private Sector)	Form and Instruction	Modified
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)		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	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

OMB Control No: 1235-0003	ICR Reference No: 202306-1235-001
Status: Active	Previous ICR Reference No: 202304-1235-001
Agency/Subagency: DOL/WHD	Agency Tracking No:
Title: The Family and Medical Leave Act of 1993, As Amended
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/09/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/06/2023
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2026	06/30/2026	06/30/2026
Responses	73,720,629	0	72,699,867
Time Burden (Hours)	8,685,596	0	8,540,897
Cost Burden (Dollars)	195,834,007	0	195,834,054

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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:
	87 FR 67718	11/09/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 26344	04/28/2023
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-385-V, WH-384, WH-380-E, WH-380-F	Certification for Serious Injury or Illness of a Current Servicemember for Military Caregiver Leave under the Family and Medical Leave Act ,   Certification for Serious Injury or Illness of a Veteran for Military Caregiver Leave under the Family and Medical Leave Act ,   Certification for Military Family Leave for Qualifying Exigency under the Family and Medical Leave Act ,   Certification of Health Care Provider for Employee's Serious Health Condition under the Family and Medical Leave Act ,   Certification of Health Care Provider for Family Member's Serious Health Condition under the 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 under the Family and Medical Leave Act
Notice to Employee of FMLA Designation (Private Sector)	WH-382	Designation Notice under the Family and Medical Leave Act
Notice to Employee of FMLA Designation (State, local, tribal)	WH-382	Designation Notice under the Family and Medical Leave Act
Notice to Employee of FMLA Eligibility and Rights & Responsibilities (Private Sector)	WH-381	Notice of Eligibility & Rights and Responsibilities under the Family and Medical Leave Act
Notice to Employee of FMLA Eligibility and Rights & Responsibilities (State, local, tribal)	WH-381	Notice of Eligibility & Rights and Responsibilities under the Family and Medical Leave Act
Notice to Employee of FMLA Eligibilty and Rights & Responsibilities (Federal)	WH-381	Notice of Eligibility & Rights and Responsibilities under the 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	73,720,629	72,699,867	0	0	1,020,762	0
Annual Time Burden (Hours)	8,685,596	8,540,897	0	0	144,699	0
Annual Cost Burden (Dollars)	195,834,007	195,834,054	0	0	-47	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: Changes reported on the burden worksheet do not result from changes to the regulations; they result because updated data has been used, resulting in adjustments to the burden worksheet.

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Annual Cost to Federal Government: $72,356

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

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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: 06/06/2023

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