Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Documenting Family Relationship Modified 183987 15332 0
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 Modified 12080153 4009851 162821810 Form and Instruction WH-380-E Certification of Health Care Provider for Employee�s Serious Health Condition
Form and Instruction WH-380-F Certification of Health Care Provider for Family Member�s Serious Health Condition
Form and Instruction WH-384 Certification of Qualifying Exigency For Military Family Leave
Form and Instruction WH-385 Certification for Serious Injury or Illness of Covered Servicemember--for Military Family Leave (Family and Medical Leave Act)
Employee's Notice of Need for FMLA Leave Modified 13419050 447302 0
Fitness-For-Duty Medical Certifications Removed 0 0 0
General FMLA Recordkeeping (State, local, tribal) New 3481350 72528 0
General FMLA Recordkeeping (Federal) New 3152 66 0
General FMLA Recordkeeping (Private Sector) Modified 9934548 206970 0
Key Employee Notification (Federal) New 11 1 0
Key Employee Notification (Private Sector) Modified 31676 2640 0
Key Employee Notification (State, local, tribal) New 11100 925 0
Notice to Employee of Change of 12-Month Period for Determining Entitlement (Federal) New 2351 1 0
Notice to Employee of Change of 12-Month Period for Determining Entitlement (Private Sector) Modified 7092303 3533 0
Notice to Employee of Change of 12-Month Period for Determining Entitlement (State, local, tribal) New 2485346 1238 0
Notice to Employee of FMLA Designation (Federal) New 4083 1102 0 Form and Instruction WH-382 Designation Notice (Family and Medical Leave Act)
Notice to Employee of FMLA Designation (Private Sector) Modified 12869427 3474802 0 Form and Instruction WH-382 Designation Notice (Family and Medical Leave Act)
Notice to Employee of FMLA Designation (State, local, tribal) New 4509815 1217670 0 Form and Instruction WH-382 Designation Notice (Family and Medical Leave Act)
Notice to Employee of FMLA Eligibility and Rights & Responsibilities (Private Sector) Modified 16113246 7026841 0 Form and Instruction WH-381 Notice of Eligibility and Rights & Responsibilities
Notice to Employee of FMLA Eligibility and Rights & Responsibilities (State, local, tribal) New 5646542 2462406 0 Form and Instruction WH-381 Notice of Eligibility and Rights & Responsibilities
Notice to Employee of FMLA Eligibilty and Rights & Responsibilities (Federal) New 5112 2229 0 Form and Instruction WH-381 Notice of Eligibility and Rights & Responsibilities
Notice to Employee of Pending Cancellation of Health Benefits (Federal) New 34 3 0
Notice to Employee of Pending Cancellation of Health Benefits (Private Sector) Modified 105585 8799 0
Notice to Employee of Pending Cancellation of Health Benefits (State, local, tribal) New 37000 3083 0
Periodic Employee Status Report Modified 369704 12323 0
Written Guidance to Employees of FMLA Rights (Handbooks/Manuals) Removed 0 0 0
Total burden requested under this ICR: 88385575 18969645 162821810  
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