Family and Medical Leave Act of 1993, As Amended

Forms and Documents

Document Name	Status
Form WH-382 Notice to Employee of FMLA Designation (Federal) Form and Instruction	Unchanged
Form WH-381 Notice to Employee of FMLA Eligibilty and Rights & Responsibilities (Federal) Form and Instruction	Unchanged
Form WH-381 Notice to Employee of FMLA Eligibility and Rights & Responsibilities (State, local, tribal) Form and Instruction	Unchanged
Form WH-382 Notice to Employee of FMLA Designation (State, local, tribal) Form and Instruction	Unchanged
Form WH-382 Notice to Employee of FMLA Designation (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-384 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 nonmaterial change 1235-0003.docx Justification for No Material/Nonsubstantive Change	2015-07-02
WH-380-E 7-2-15.docx Supplementary Document	2015-07-02
WH-385-V (12-20-14),trk chg.pdf Supplementary Document	2014-12-19
WH-380-F (12-19-14), trk change.pdf Supplementary Document	2014-12-19
WH-385 (12-19-14), trk chg.pdf Supplementary Document	2014-12-19
FMLA 60day FR notice 9-11-14.pdf Supplementary Document	2014-11-14
employeeguide(3.26.13).pdf Supplementary Document	2013-03-26
ss1235-0003 20150215.docx Supporting Statement A	2015-02-17

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	Unchanged
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	Unchanged
186913	Notice to Employee of FMLA Eligibility and Rights & Responsibilities (State, local, tribal) Form and Instruction	Unchanged
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	Unchanged
186898	General FMLA Recordkeeping (Federal)	Unchanged
186891	Key Employee Notification (State, local, tribal)	Unchanged
186890	General FMLA Recordkeeping (State, local, tribal)	Unchanged
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	Unchanged
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)	Unchanged
178607	Employee's Notice of Need for FMLA Leave	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

ICR Details

OMB Control No: 1235-0003	ICR Reference No: 201507-1235-001
Status: Historical Active	Previous ICR Reference No: 201410-1235-004
Agency/Subagency: DOL/WHD	Agency Tracking No:
Title: Family and Medical Leave Act of 1993, As Amended
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/16/2015
	Date Received in OIRA: 07/09/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2018	05/31/2018	05/31/2018
Responses	82,371,724	0	82,371,724
Time Burden (Hours)	9,313,503	0	9,313,503
Cost Burden (Dollars)	184,932,912	0	184,932,912

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Abstract: The DOL created the subject information collections (i.e., notifications) to implement 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.

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Authorizing Statute(s): US Code: 29 USC 2601, et seq. Name of Law: Family and Medical Leave Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
1235-AA09	Final or interim final rulemaking	80 FR 9989	02/25/2015

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 54299	11/11/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 10162	02/25/2015
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 22

IC Title	Form No.	Form Name
Notice to Employee of Change of 12-Month Period for Determining Entitlement (Federal)
Notice to Employee of Pending Cancellation of Health Benefits (Federal)
Key Employee Notification (State, local, tribal)
Key Employee Notification (Federal)
Periodic Employee Status Report
Notice to Employee of FMLA Designation (Private Sector)	WH-382	Designation Notice (Family and Medical Leave Act)
Documenting Family Relationship
Employee's Notice of Need for FMLA Leave
Notice to Employee of Change of 12-Month Period for Determining Entitlement (Private Sector)
Key Employee Notification (Private Sector)
General FMLA Recordkeeping (Private Sector)
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	WH-384, WH-385, WH-380-F, WH-385-V, WH-380-E	Certification of Qualifying Exigency for Military Family Leave (Family and Medical Leave Act) ,   Certification for Serious Injury or Illness of a Current Servicemember - - for Military Family Leave (Family and Medical Leave Act) ,   Certification of Health Care Provider for Family Member's Serious Health Condition (Family and Medical Leave Act) ,   Certification for Serious Injury or illness of a Veteran for Military Caregiver Leave (Family and Medical Leave Act) ,   Certification of Health Care Provider for Employee's Serious Health Condition (Family and Medical Leave Act)
Notice to Employee of FMLA Eligibility and Rights & Responsibilities (Private Sector)	WH-381, WH-381	Notice of Eligibility and Rights and Responsibilities (Family and Medical Leave Act) ,   Notice of Eligibility and Rights and Responsibilities (Family and Medical Leave Act)
General FMLA Recordkeeping (State, local, tribal)
Notice to Employee of Pending Cancellation of Health Benefits (Private Sector)
General FMLA Recordkeeping (Federal)
Notice to Employee of Change of 12-Month Period for Determining Entitlement (State, local, tribal)
Notice to Employee of FMLA Eligibility and Rights & Responsibilities (State, local, tribal)	WH-381	Notice of Eligibility and Rights and Responsibilities (Family and Medical Leave Act)
Notice to Employee of FMLA Designation (State, local, tribal)	WH-382	Designation Notice (Family and Medical Leave Act)
Notice to Employee of Pending Cancellation of Health Benefits (State, local, tribal)
Notice to Employee of FMLA Designation (Federal)	WH-382	Designation Notice (Family and Medical Leave Act)
Notice to Employee of FMLA Eligibilty and Rights & Responsibilities (Federal)	WH-381	Notice of Eligibility and Rights and Responsibilities (Family and Medical Leave Act)

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ICR Summary of Burden

	Total Approved	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	82,371,724	82,371,724	0	0	0	0
Annual Time Burden (Hours)	9,313,503	9,313,503	0	0	0	0
Annual Cost Burden (Dollars)	184,932,912	184,932,912	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: There is a slight increase upon existing responses, burden hours, and burden costs associated with this final rule. The changed paperwork burden estimates stem from two fundamental changes. First, the expansion of FMLA leave to employees to care for same-sex spouses and the stepchildren or stepparents of same-sex spouses, regardless of their state of residence. Second, increased wage rates for persons completing the information collections and other higher costs, as discussed in Item 13 of the supporting statement. The federal costs have also increased, in spite of utilizing double-sided printing, due to increases in postage prices. However, the respondents, responses, burden hours, and burden costs will now appear to be significantly lower than in the most recent FMLA rulemaking supporting statement. These changes principally stemmed from the Department's detection of the duplicative counting of respondents in an earlier rulemaking. This supporting statement has corrected those mathematical equations. Because some of those calculations result in different numbers of responses, burden hours and burden costs, the Department has carefully detailed the basis and steps to its current computations. Another change to this supporting statement, also for the purposes of clarity and transparency, is more clearly detailing the Department's attribution of hours and costs to employees, health care providers, and employers, respectively.

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Annual Cost to Federal Government: $784,860

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? 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? Uncollected

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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: 07/09/2015

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