The Family and Medical Leave Act of 1993, As Amended

ICR 202306-1235-001

OMB: 1235-0003

Federal Form Document

Forms and Documents

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

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	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