Norristown Area School District Family & Medical Leave Forms Kit Page 9
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Signature of Health Care Provider
Date
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.
Page 4
FormWH-380-E Revised January 2009
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