Model Employer CHIP Notice (Private Sector Burden)

Model Employer Children's Health Insurance Program Notice

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1210-0137 can be found here:

Documents and Forms

Document Name Document Type
chipmodelnotice 7-31-13.doc www.dol.gov/ebsa/chipmodelnotice.doc Other-Model Notice

Information Collection (IC) Details

IC Title:	Model Employer CHIP Notice (Private Sector Burden)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Model Notice			chipmodelnotice 7-31-13.doc	http://www.dol.gov/ebsa/chipmodelnotice.doc	Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,961,000	Number of Respondents for Small Entity: 38

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

Percentage of Respondents Reporting Electronically: 38 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	174,347,154	-29,447,846	203,795,000
Annual IC Time Burden (Hours)	900,519	-152,481	1,053,000
Annual IC Cost Burden (Dollars)	21,619,363	-3,651,637	25,271,000

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.