The Family and Medical Leave Act of 1993, As Amended

OMB 1235-0003

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.

The latest form for The Family and Medical Leave Act of 1993, As Amended expires 2023-06-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form WH-382 Notice to Employee of FMLA Designation (Federal) Form and Instruction
Form WH-382 Notice to Employee of FMLA Designation (Federal) Form and Instruction
Form WH-381 Notice to Employee of FMLA Eligibilty and Rights & Responsibilities (Federal) Form and Instruction
Form WH-381 Notice to Employee of FMLA Eligibilty and Rights & Responsibilities (Federal) Form and Instruction
Form WH-381 Notice to Employee of FMLA Eligibility and Rights & Responsibilities (State, local, tribal) Form and Instruction
Form WH-381 Notice to Employee of FMLA Eligibility and Rights & Responsibilities (State, local, tribal) Form and Instruction
Form WH-382 Notice to Employee of FMLA Designation (State, local, tribal) Form and Instruction
Form WH-382 Notice to Employee of FMLA Designation (State, local, tribal) Form and Instruction
Form WH-382 Notice to Employee of FMLA Designation (Private Sector) Form and Instruction
Form WH-382 Notice to Employee of FMLA Designation (Private Sector) Form and Instruction
Form WH-381 Notice to Employee of FMLA Eligibility and Rights & Responsibilities (Private Sector) Form and Instruction
Form WH-381 Notice to Employee of FMLA Eligibility and Rights & Responsibilities (Private Sector) Form and Instruction
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
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
Justification for Nonsubstantive Change 1235-0003 (2023-06-02).docx Justification for No Material/Nonsubstantive Change
Justification for Nonsubstantive Change 1235-0003 (2023-06-02).docx Justification for No Material/Nonsubstantive Change
60-day FR notice 2022-11-09.pdf Supplementary Document
60-day FR notice 2022-11-09.pdf Supplementary Document
Supporting Statement 1235-0003 (2023-06-06).docx Supporting Statement A
Supporting Statement 1235-0003 (2023-06-06).docx Supporting Statement A
Notice to Employee of Change of 12-Month Period for Determining Entitlement (Federal)
Notice to Employee of Pending Cancellation of Health Benefits (Federal)
Notice to Employee of FMLA Designation (Federal) Form and Instruction
Notice to Employee of FMLA Designation (Federal) Form and Instruction
Key Employee Notification (Federal)
Notice to Employee of Change of 12-Month Period for Determining Entitlement (State, local, tribal)
Notice to Employee of FMLA Eligibilty and Rights & Responsibilities (Federal) Form and Instruction
Notice to Employee of FMLA Eligibilty and Rights & Responsibilities (Federal) Form and Instruction
Notice to Employee of FMLA Eligibility and Rights & Responsibilities (State, local, tribal) Form and Instruction
Notice to Employee of FMLA Eligibility and Rights & Responsibilities (State, local, tribal) Form and Instruction
Notice to Employee of Pending Cancellation of Health Benefits (State, local, tribal)
Notice to Employee of FMLA Designation (State, local, tribal) Form and Instruction
Notice to Employee of FMLA Designation (State, local, tribal) Form and Instruction
General FMLA Recordkeeping (Federal)
Key Employee Notification (State, local, tribal)
General FMLA Recordkeeping (State, local, tribal)
Notice to Employee of Pending Cancellation of Health Benefits (Private Sector)
Documenting Family Relationship
Periodic Employee Status Report
Notice to Employee of FMLA Designation (Private Sector) Form and Instruction
Notice to Employee of FMLA Designation (Private Sector) Form and Instruction
General FMLA Recordkeeping (Private Sector)
Key Employee Notification (Private Sector)
Notice to Employee of Change of 12-Month Period for Determining Entitlement (Private Sector)
Employee's Notice of Need for FMLA Leave
Notice to Employee of FMLA Eligibility and Rights & Responsibilities (Private Sector) Form and Instruction
Notice to Employee of FMLA Eligibility and Rights & Responsibilities (Private Sector) Form and Instruction
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
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

All Historical Document Collections

202306-1235-001 Approved without change	No material or nonsubstantive change to a currently approved collection	2023-06-06
202304-1235-001 Approved with change	Extension without change of a currently approved collection	2023-04-28
202302-1235-002 Approved without change	No material or nonsubstantive change to a currently approved collection	2023-02-27
201910-1235-001 Approved without change	Revision of a currently approved collection	2020-03-19
201711-1235-001 Approved without change	Extension without change of a currently approved collection	2018-04-20
201507-1235-001 Approved without change	No material or nonsubstantive change to a currently approved collection	2015-07-09
201410-1235-004 Approved with change	Revision of a currently approved collection	2015-02-25
201408-1235-001 Approved without change	No material or nonsubstantive change to a currently approved collection	2014-09-08
201404-1235-001 Comment filed on proposed rule and continue	Revision of a currently approved collection	2014-06-27
201303-1235-001 Approved without change	No material or nonsubstantive change to a currently approved collection	2013-03-27
201302-1235-001 Approved without change	Revision of a currently approved collection	2013-02-06
201207-1235-001 Preapproved	Revision of a currently approved collection	2013-01-24
201202-1235-002 Comment filed on proposed rule and continue	Revision of a currently approved collection	2012-02-22
201112-1235-003 Approved without change	Revision of a currently approved collection	2011-12-29
201003-1235-003 Approved with change	Revision of a currently approved collection	2010-03-12

OMB Details

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

Federal Enterprise Architecture: Workforce Management - Labor Rights Management

Form WH-380-E	Certification of Health Care Provider for Employee's Serious Health Condition under the Family and Medical Leave Act	www.dol.gov/whd/forms/WH-380-E.pdf	Form and instruction
Form WH-384	Certification for Military Family Leave for Qualifying Exigency under the Family and Medical Leave Act	www.dol.gov/whd/forms/WH-384.pdf	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	www.dol.gov/whd/forms/wh385v.pdf	Form and instruction
Form WH-385	Certification for Serious Injury or Illness of a Current Servicemember for Military Caregiver Leave under the Family and Medical Leave Act	www.dol.gov/whd/forms/WH-385.pdf	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	www.dol.gov/whd/forms/wh-380-f.pdf	Form and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.