Information Collection Request

The Family and Medical Leave Act of 1993, As Amended

ICR 202304-1235-001 · OMB 1235-0003 · Received in OIRA

⚠️ Notice: This information collection may be outdated. More recent filings for OMB 1235-0003 can be found here:

2023-06-06 - No material or nonsubstantive change to a currently approved collection

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	Modified
Form WH-381 Notice to Employee of FMLA Eligibility and Rights & Responsibilities (Private Sector) Form and Instruction	Modified
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	Modified
60-day FR notice 2022-11-09.pdf Supplementary Document	2023-04-13
Supporting Statement 1235-0003 (2023-04-24).docx Supporting Statement A	2023-04-24

IC Document Collections

IC ID	Document Title	Status
187163	Notice to Employee of Change of 12-Month Period for Determining Entitlement (Federal)	Modified
187079	Notice to Employee of Pending Cancellation of Health Benefits (Federal)	Modified
187078	Notice to Employee of FMLA Designation (Federal) Form and Instruction	Unchanged
187073	Key Employee Notification (Federal)	Modified
186957	Notice to Employee of Change of 12-Month Period for Determining Entitlement (State, local, tribal)	Modified
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)	Modified
182234	Notice to Employee of Pending Cancellation of Health Benefits (Private Sector)	Modified
182233	Documenting Family Relationship	Modified
182083	Periodic Employee Status Report	Unchanged
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
178653	Notice to Employee of Change of 12-Month Period for Determining Entitlement (Private Sector)	Modified
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

Status	Received in OIRA
Agency/Subagency	DOL/WHD
OMB Control No	1235-0003
Type of Information Collection	Extension without change of a currently approved collection
Previous ICR Reference No	202302-1235-002
Date Submitted to OIRA	1969-12-31
Requested Expiration Date	1969-12-31