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Self-Certification or Notification
Coverage of Certain Preventive Services Under the Affordable Care Act-For-Profit Entities
OMB: 1210-0152
IC ID: 212710
OMB.report
DOL/EBSA
OMB 1210-0152
ICR 201506-1210-001
IC 212710
( )
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
View Information Collection (IC)
IC Title:
Self-Certification or Notification
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
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
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
105
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
105
0
105
0
0
0
Annual IC Time Burden (Hours)
131
0
131
0
0
0
Annual IC Cost Burden (Dollars)
23
0
23
0
0
0
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.