Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Documenting Family Relationship Modified 186095 15507 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 12128661 4027027 163536586 Form and Instruction WH-380-F Certification of Health Care Provider for Family Member Serious Health Condition
Form and Instruction WH-380-E Certification of Health Care Provider for Employee's Serious Health Condition
Form and Instruction WH-384 Certification of Qualifying Exigency for Military Family Leave (Family and Medical Leave Act)
Form and Instruction WH-385 Certification for Serious Injury or Illness of a Current Servicemember for Military Family Leave (Family and Medical Leave Act)
Form and Instruction WH-385-V Certification for a Serious Injury or Illness of a Veteran for Military Caregiver Leave (Family and Medical Leave Act)
Employee's Notice of Need for FMLA Leave Modified 14190500 473017 0
General FMLA Recordkeeping (State, local, tribal) Unchanged 3481350 72528 0
General FMLA Recordkeeping (Federal) Unchanged 3152 66 0
General FMLA Recordkeeping (Private Sector) Unchanged 9934548 206970 0
Key Employee Notification (Federal) Unchanged 11 1 0
Key Employee Notification (Private Sector) Unchanged 31676 2640 0
Key Employee Notification (State, local, tribal) Unchanged 11100 925 0
Notice to Employee of Change of 12-Month Period for Determining Entitlement (Federal) Unchanged 2351 1 0
Notice to Employee of Change of 12-Month Period for Determining Entitlement (Private Sector) Unchanged 7099082 3536 0
Notice to Employee of Change of 12-Month Period for Determining Entitlement (State, local, tribal) Unchanged 2487721 1239 0
Notice to Employee of FMLA Designation (Federal) Modified 4095 1104 0 Form and Instruction WH-382 Designation Notice
Notice to Employee of FMLA Designation (Private Sector) Modified 12906924 3481051 0 Form and Instruction WH-382 Designation Notice
Notice to Employee of FMLA Designation (State, local, tribal) Modified 4522955 1219860 0 Form and Instruction WH-382 Designation Notice
Notice to Employee of FMLA Eligibility and Rights & Responsibilities (Private Sector) Modified 16150743 7033091 0 Form and Instruction WH-381 Notice of Eligibility and Rights and Responsibilities (Family and Medical Leave Act)
Notice to Employee of FMLA Eligibility and Rights & Responsibilities (State, local, tribal) Modified 5659681 2464596 0 Form and Instruction WH-381 Notice of Eligibility and Rights and Responsibilities
Notice to Employee of FMLA Eligibilty and Rights & Responsibilities (Federal) Modified 5124 2231 0 Form and Instruction WH-381 Notice of Eligibility and Rights and Responsibilities
Notice to Employee of Pending Cancellation of Health Benefits (Federal) Unchanged 34 3 0
Notice to Employee of Pending Cancellation of Health Benefits (Private Sector) Unchanged 105585 8799 0
Notice to Employee of Pending Cancellation of Health Benefits (State, local, tribal) Unchanged 37000 3083 0
Periodic Employee Status Report Unchanged 371897 12396 0
Total burden requested under this ICR: 89320285 19029671 163536586  
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