Notice to Employee of Pending Cancellation of Health Benefits (Private Sector)

29 C.F.R. Part 825, The Family and Medical Leave Act of 1993

Documents and Forms

Document Name Document Type

no available documents/forms check other ICs listed under this ICR

Information Collection (IC) Details

IC Title:	Notice to Employee of Pending Cancellation of Health Benefits (Private Sector)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 29 CFR 825.212(a)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Workforce Management

Subfunction: Labor Rights Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 105,585	Number of Respondents for Small Entity: 97,062

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Farms, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	105,585	2,138	103,447
Annual IC Time Burden (Hours)	8,799	1,777	7,022
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.