Signature of Health Care Provider
PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT
If submitted, it is mandatory for employers to retain a copy of this disclosure in their records for three years. 29
U.S.C. § 2616; 29 C.F.R. § 825.500.Persons are not required to respond to this collection of information unless it
displays a currently valid OMB control number. The Department of Labor estimates that it will take an average of 20
minutes for respondents to complete this collection of information, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. If you have any comments regarding this burden estimate or any other aspect of this
collection information, including suggestions for reducing this burden, send them to the Administrator, Wage and
Hour Division, U.S. Department of Labor, Room S-3502, 200 Constitution Ave., NW, Washington, DC 20210.
DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR; RETURN TO THE PATIENT.