Employment Information Form

Forms and Documents

Document Name	Status
Form WH-3 English Employment Information form Form and Instruction	New
empsitApr 2023.pdf Supplementary Document	2023-07-02
Supporting Statement 1235-0NEW v1.1 (2023-07-22) NPRM 541.docx Supporting Statement A	2023-08-20

IC Document Collections

IC ID	Document Title	Status
260904	Employment Information form Form and Instruction	New

ICR Details

OMB Control No:	ICR Reference No: 202306-1235-004
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: DOL/WHD	Agency Tracking No:
Title: Employment Information Form
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 09/08/2023

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	28,824	0
Time Burden (Hours)	9,608	0
Cost Burden (Dollars)	0	0

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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. This is a duplicate ICR of 1235-0021 to allow the public to comment on NPRM 1235-AA39.

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Authorizing Statute(s): US Code: 29 USC 211 Name of Law: Fair Labor Standards Act
   US Code: 29 USC 2616 Name of Law: Family and Medical Leave Act
   US Code: 29 USC 1862 Name of Law: Migrant and Seasonal Agriculture 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 353 Name of Law: McNamara-O'Hara Service Contract Act
   US Code: 19 USC 4532 Name of Law: U.S.-Mexico-Canada Trade Agreement
   US Code: 29 USC 2004 Name of Law: Employee Polygraph Protection Act
   US Code: 41 USC 38 Name of Law: Walsh-Healey Public Contracts Act
   US Code: 8 USC 1188 Name of Law: Immigration and Nationality Act
   EO: EO 13658 Name/Subject of EO: Establishing a Minimum Wage for Federal Contractors
   EO: EO 13706 Name/Subject of EO: Establishing Paid Sick Leave for Federal Contractors
   EO: EO 14026 Name/Subject of EO: Increasing the Minimum Wage for Federal Contractors
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
1235-AA39	Proposed rulemaking	88 FR 62152	09/08/2023

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Employment Information form	WH-3 English, WH-3 Spanish	Employment Information Form ,   Employment Information Form

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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	28,824	0	0	0	28,824	0
Annual Time Burden (Hours)	9,608	0	0	0	9,608	0
Annual Cost Burden (Dollars)	0	0	0	0	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: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

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: 09/08/2023

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