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

Document Name Document 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)

IC Title:	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	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 29 CFR 825.100(d) 29 CFR 825.216(b) 29 CFR 825.310 29 CFR 825.306 29 CFR 825.308 29 CFR 825.307 29 CFR 825.213(a)(3) 29 CFR 825.312 29 CFR 825.305 29 CFR 825.309

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	WH-385	Certification for Serious Injury or Illness of a Current Servicemember for Military Caregiver Leave under the Family and Medical Leave Act	WH-385 02.06.20.docx	https://www.dol.gov/whd/forms/WH-385.pdf	Yes	No	Fillable Printable
Form and Instruction	WH-385-V	Certification for Serious Injury or Illness of a Veteran for Military Caregiver Leave under the Family and Medical Leave Act	WH-385-V 02.06.20.docx	https://www.dol.gov/whd/forms/wh385v.pdf	Yes	No	Fillable Printable
Form and Instruction	WH-384	Certification for Military Family Leave for Qualifying Exigency under the Family and Medical Leave Act	WH-384 02.06.20.docx	https://www.dol.gov/whd/forms/WH-384.pdf	Yes	No	Fillable Printable
Form and Instruction	WH-380-E	Certification of Health Care Provider for Employee's Serious Health Condition under the Family and Medical Leave Act	WH-380-E.pdf	www.dol.gov/agencies/whd/fmla	Yes	No	Fillable Printable
Form and Instruction	WH-380-F	Certification of Health Care Provider for Family Member's Serious Health Condition under the Family and Medical Leave Act	WH-380-F.pdf	https://www.dol.gov/sites/dolgov/files/WHD/legacy/files/WH-380-F.pdf	Yes	No	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Workforce Management

Subfunction: Labor Rights Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 8,263,720	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	10,381,263	479,423	9,901,840
Annual IC Time Burden (Hours)	2,475,556	114,325	2,361,231
Annual IC Cost Burden (Dollars)	251,749,336	55,915,329	195,834,007

Documents for IC

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.

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