29 C.F.R. Part 825, The Family and Medical Leave Act of 1993

Forms and Documents

Document Name	Status
Form WH-382 Notice to Employee of FMLA Designation (Federal) Form and Instruction	New
Form WH-381 Notice to Employee of FMLA Eligibilty and Rights & Responsibilities (Federal) Form and Instruction	New
Form WH-381 Notice to Employee of FMLA Eligibility and Rights & Responsibilities (State, local, tribal) Form and Instruction	New
Form WH-382 Notice to Employee of FMLA Designation (State, local, tribal) Form and Instruction	New
Form WH-382 Notice to Employee of FMLA Designation (Private Sector) Form and Instruction	Modified
Form WH-381 Notice to Employee of FMLA Eligibility and Rights & Responsibilities (Private Sector) Form and Instruction	Modified
Form WH-380-E 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
1215-0181ss(20081212)[1].doc Supporting Statement A	2008-12-12
1215-0181 Note to the Reviewer(2008111).doc Supplementary Document	2008-11-11

IC Document Collections

IC ID	Document Title	Status
187163	Notice to Employee of Change of 12-Month Period for Determining Entitlement (Federal)	New
187079	Notice to Employee of Pending Cancellation of Health Benefits (Federal)	New
187078	Notice to Employee of FMLA Designation (Federal) Form and Instruction	New
187073	Key Employee Notification (Federal)	New
186957	Notice to Employee of Change of 12-Month Period for Determining Entitlement (State, local, tribal)	New
186955	Notice to Employee of FMLA Eligibilty and Rights & Responsibilities (Federal) Form and Instruction	New
186913	Notice to Employee of FMLA Eligibility and Rights & Responsibilities (State, local, tribal) Form and Instruction	New
186900	Notice to Employee of Pending Cancellation of Health Benefits (State, local, tribal)	New
186899	Notice to Employee of FMLA Designation (State, local, tribal) Form and Instruction	New
186898	General FMLA Recordkeeping (Federal)	New
186891	Key Employee Notification (State, local, tribal)	New
186890	General FMLA Recordkeeping (State, local, tribal)	New
182234	Notice to Employee of Pending Cancellation of Health Benefits (Private Sector)	Modified
182233	Documenting Family Relationship	Modified
182083	Periodic Employee Status Report	Modified
182081	Notice to Employee of FMLA Designation (Private Sector) Form and Instruction	Modified
178656	General FMLA Recordkeeping (Private Sector)	Modified
178655	Key Employee Notification (Private Sector)	Modified
178654	Fitness-For-Duty Medical Certifications	Removed
178653	Notice to Employee of Change of 12-Month Period for Determining Entitlement (Private Sector)	Modified
178608	Written Guidance to Employees of FMLA Rights (Handbooks/Manuals)	Removed
178607	Employee's Notice of Need for FMLA Leave	Modified
178568	Notice to Employee of FMLA Eligibility and Rights & Responsibilities (Private Sector) Form and Instruction	Modified
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: 201003-1235-003
Status: Historical Active	Previous ICR Reference No: 200709-1215-004
Agency/Subagency: DOL/WHD	Agency Tracking No:
Title: 29 C.F.R. Part 825, The Family and Medical Leave Act of 1993
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 03/12/2010
	Date Received in OIRA: 03/12/2010
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2011	36 Months From Approved
Responses	88,385,575	0	15,058,850
Time Burden (Hours)	18,969,645	0	1,370,288
Cost Burden (Dollars)	162,821,810	0	11,915,480

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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) and by the amemdments to FMLA contained in National Defense Authorization Act for FY 2008 (NDAA), Pub. L. No. 110-181. 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: PL: Pub.L. 101 - 181 585(a)(s)-(3)(D) Name of Law: National Defense Authorization Act for Fiscal Year 2008

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
1215-AB35	Final or interim final rulemaking	73 FR 67933	11/17/2008

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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: 22

IC Title	Form No.	Form Name
Fitness-For-Duty Medical Certifications
Notice to Employee of Change of 12-Month Period for Determining Entitlement (Federal)
Notice to Employee of FMLA Eligibility and Rights & Responsibilities (State, local, tribal)	WH-381	Notice of Eligibility and Rights & Responsibilities
Notice to Employee of FMLA Eligibilty and Rights & Responsibilities (Federal)	WH-381	Notice of Eligibility and Rights & Responsibilities
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-380-F, WH-384, WH-385, WH-380-E	Certification of Health Care Provider for Employee�s Serious Health Condition ,   Certification of Health Care Provider for Family Member�s Serious Health Condition ,   Certification of Qualifying Exigency For Military Family Leave ,   Certification for Serious Injury or Illness of Covered Servicemember--for Military Family Leave (Family and Medical Leave Act)
Notice to Employee of FMLA Eligibility and Rights & Responsibilities (Private Sector)	WH-381	Notice of Eligibility and Rights & Responsibilities
Written Guidance to Employees of FMLA Rights (Handbooks/Manuals)
Notice to Employee of Pending Cancellation of Health Benefits (Private Sector)
General FMLA Recordkeeping (State, local, tribal)
General FMLA Recordkeeping (Federal)
Notice to Employee of Change of 12-Month Period for Determining Entitlement (State, local, tribal)
Notice to Employee of Pending Cancellation of Health Benefits (Federal)
Key Employee Notification (State, local, tribal)
Key Employee Notification (Federal)
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)

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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	88,385,575	15,058,850	14,827,012	4,669	58,495,044	0
Annual Time Burden (Hours)	18,969,645	1,370,288	3,482,473	7,020,126	7,096,758	0
Annual Cost Burden (Dollars)	162,821,810	11,915,480	455,927	0	150,450,403	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Changing Regulations

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Changing Regulations

Short Statement: In addition to the 3,482,473 burden hour increase that occured as a result of new statutory requirements, discretionary changes were made to the regulations -- adding and deleting specific notification requirements -- that resulted in an increase of 7,020,126 hours. The burden estimates were also adjusted upward by 7,096,758 because of improved information on the number of respondents subject to the FMLA paperwork requirements, recalculation of burden based on a more disaggregated approach, and a reconsideration of whether certain regulations impose a burden beyond what employees and employers customarily would do in the absence of the regulations. The estimated annual cost burden has increased due to an increase in maintenance and operations costs of $150,906,330, of which $455,927 are based on statutory changes and the remainder is due to the reasons mentioned above, as well as, increased wage rates and other costs for persons completing the information collections.

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Annual Cost to Federal Government: $651,550

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]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

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: 11/17/2008

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