Employment Information Form

Forms and Documents

Document Name	Status
Form WH-3 Sp Employment Information Form Form and Instruction	Modified
1235-0021ss WH-3(2010).doc Supporting Statement A	2010-07-08

IC Document Collections

IC ID	Document Title	Status
13616	Employment Information Form Form and Instruction	Modified

ICR Details

OMB Control No: 1235-0021	ICR Reference No: 201007-1235-001
Status: Historical Active	Previous ICR Reference No: 201003-1235-021
Agency/Subagency: DOL/WHD	Agency Tracking No:
Title: Employment Information Form
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/23/2010
	Date Received in OIRA: 07/20/2010
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2013	36 Months From Approved	09/30/2010
Responses	35,000	0	35,000
Time Burden (Hours)	11,667	0	11,667
Cost Burden (Dollars)	0	0	0

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Abstract: Form WH-3 is an optional form complainants (e.g., current and former employees, unions, and, competitor employers) may use to provide information about alleged violations of the labor standards administered by the Wage and Hour Division (WHD) of the U.S. Department of Labor. Complaints themselves or WHD staff, using information provided by the complainants, complete the forms. WHD staff use the completed to obtain information about employer compliance with the provisions of the various labor standards laws enforced by the WHD and to determine if the agency has jurisdiction to investigate the alleged violation(s). WHD makes for form available in both English and Spanish. When the WHD schedules a complaint-based investigation, the agency makes the completed Form WH-3 part of the investigation case file.

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Authorizing Statute(s): US Code: 29 USC 211(a) Name of Law: Fair Labor Standards Act
   US Code: 29 USC 1862(a) Name of Law: Migrant and Seasonal Agricultural Worker Protection Act
   US Code: 29 USC 2004(a)(3) Name of Law: Employee Polygraph Protection Act
   US Code: 29 USC 2616(a) Name of Law: Family and Medical Leave Act
   US Code: 15 USC 1676 Name of Law: Consumer Credit Protection Act
   US Code: 40 USC 3141 Name of Law: Davis Bacon Act
   US Code: 41 USC 38 Name of Law: Walsh-Healey Public Contracts Act
   US Code: 41 USC 353(a) Name of Law: McNamara-O'Hara Service Contract Act
   US Code: 8 USC 1188(g) Name of Law: Immigration and Nationality Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 63159	12/02/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 38124	07/01/2010
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Employment Information Form	WH-3, WH-3 Sp	Employment Information Form (Spanish) ,   Employment Information Form

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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	35,000	35,000	0	0	0	0
Annual Time Burden (Hours)	11,667	11,667	0	0	0	0
Annual Cost Burden (Dollars)	0	0	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:

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Annual Cost to Federal Government: $624,171

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]? Uncollected

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: 07/20/2010

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