OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

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

IC 13897 under ICR 202605-1235-003 · OMB 1235-0003.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Form WH-385
Certification for Serious Injury or Illness of a Current Servicemember for Military Caregiver Leave under the Family and Medical Leave Act 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
Form WH-385-V
Certification for Serious Injury or Illness of a Veteran for Military Caregiver Leave under the Family and Medical Leave Act 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
Form WH-384
Certification for Military Family Leave for Qualifying Exigency under the Family and Medical Leave Act 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
Form WH-380-E
Certification of Health Care Provider for Employee's Serious Health Condition under the Family and Medical Leave Act 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
Form WH-380-F
Certification of Health Care Provider for Family Member's Serious Health Condition under the Family and Medical Leave Act 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
WH-385 Certification for Serious Injury or Illness of a Current
WH-385 02.06.20.docx
www.dol.gov/whd/forms/WH-385.pdf 		Form and Instruction
WH-385-V Certification for Serious Injury or Illness of a Veteran
WH-385-V 02.06.20.docx
www.dol.gov/whd/forms/wh385v.pdf 		Form and Instruction
WH-384 Certification for Military Family Leave for Qualifying E
WH-384 02.06.20.docx
www.dol.gov/whd/forms/WH-384.pdf 		Form and Instruction
WH-380-E Certification of Health Care Provider for Employee's Ser
WH-380-E.pdf
www.dol.gov/agencies/whd/fmla 		Form and Instruction
WH-380-F Certification of Health Care Provider for Family Member'
WH-380-F.pdf
www.dol.gov/sites/dolgov/files/WHD/legacy/files/WH-380-F.pdf 		Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

layout table

Information Collection Instruments:
table that charts list of instruments
Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction WH-385 https://www.dol.gov/whd/forms/WH-385.pdf Yes No Fillable Printable
Form and Instruction WH-385-V https://www.dol.gov/whd/forms/wh385v.pdf Yes No Fillable Printable
Form and Instruction WH-384 https://www.dol.gov/whd/forms/WH-384.pdf Yes No Fillable Printable
Form and Instruction WH-380-E www.dol.gov/agencies/whd/fmla Yes No Fillable Printable
Form and Instruction WH-380-F https://www.dol.gov/sites/dolgov/files/WHD/legacy/files/WH-380-F.pdf Yes No Fillable Printable

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 10,381,263 0 0 479,423 0 9,901,840
Annual IC Time Burden (Hours) 2,475,556 0 0 114,325 0 2,361,231
Annual IC Cost Burden (Dollars) 251,749,336 0 0 55,915,329 0 195,834,007

Documents for IC
table that charts IC Documents
Title Document Date Uploaded
No associated records found
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].