Self-Certification or Notiffication

Coverage of Certain Preventive Services Under the Affordable Care Act

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1210-0150 can be found here:

Documents and Forms

Document Name Document Type
Model Notice 2014-08-20.docx 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 Notiffication	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 29 CFR 2510 29 CFR 2590

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Model Notice			Model Notice 2014-08-20.docx		Yes	Yes	Fillable Printable
Form	EBSA Form 700	Eligible Organization Self-Certification	EBSA Form 700.doc	http://www.dol.gov/ebsa/pdf/preventiveserviceseligibleorganizationcertificationform.pdf	Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 122	Number of Respondents for Small Entity: 120

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

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	122	1	119	2
Annual IC Time Burden (Hours)	51	1	48	2
Annual IC Cost Burden (Dollars)	33	0	32	1

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.