Self-Certification or Notification

Coverage of Certain Preventive Services Under the Affordable Care Act-For-Profit Entities

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1210-0152 can be found here:

Documents and Forms

Document Name Document Type
Form EBSA Form 700 Self-Certification or Notification Form
Model Notice 8 14 14.doc Other-Model Notice
EBSA Form 700 Eligible Organization Self-Certification EBSA Form 700.doc www.dol.gov/ebsa/pdf/preventiveserviceseligibleorganizationcertificationform.pdf Form

Information Collection (IC) Details

IC Title:	Self-Certification or Notification	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 29 CFR 2510

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	EBSA Form 700	Eligible Organization Self-Certification	EBSA Form 700.doc	http://www.dol.gov/ebsa/pdf/preventiveserviceseligibleorganizationcertificationform.pdf	Yes	No	Printable Only
Other-Model Notice			Model Notice 8 14 14.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 71	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	71	71
Annual IC Time Burden (Hours)	30	30
Annual IC Cost Burden (Dollars)	19	19

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.