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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
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
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
29 CFR 825.306
29 CFR 825.305
29 CFR 825.100(d)
29 CFR 825.308
29 CFR 825.310
29 CFR 825.307
29 CFR 825.213(a)(3)
29 CFR 825.216(b)
29 CFR 825.312
29 CFR 825.309
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form and Instruction
WH-380-E
Certification of Health Care Provider for Employee�s Serious Health Condition
WH-380-E(2008).doc
http://www.dol.gov/esa/whd/forms/wh-380-E.pdf
Yes
Yes
Fillable Printable
Form and Instruction
WH-380-F
Certification of Health Care Provider for Family Member�s Serious Health Condition
WH-380-F(2008).doc
http://www.dol.gov/esa/whd/forms/wh-380-F.pdf
Yes
Yes
Fillable Printable
Form and Instruction
WH-384
Certification of Qualifying Exigency For Military Family Leave
WH-384(2008).doc
http://www.dol.gov/esa/whd/forms/wh-384.pdf
Yes
Yes
Fillable Printable
Form and Instruction
WH-385
Certification for Serious Injury or Illness of Covered Servicemember--for Military Family Leave (Family and Medical Leave Act)
WH-385(2008).doc
http://www.dol.gov/esa/whd/forms/wh-385.pdf
Yes
Yes
Fillable Printable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Workforce Management
Subfunction:
Labor Rights Management
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
5,454,097
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
12,080,153
1,443,572
0
8,727,581
0
1,909,000
Annual IC Time Burden (Hours)
4,009,851
464,324
0
2,909,194
0
636,333
Annual IC Cost Burden (Dollars)
162,821,810
455,927
3,501,720
147,562,883
0
11,301,280
Documents for IC
Title
Document
Date Uploaded
No associated records found
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.