Notice Requirements of the Health Care Continuation Coverage Provisions

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1210-0123 can be found here:

Documents and Forms

Document Name Document Type
modelgeneralnotice 5 1 14 230pm.doc Other-COBRA Model General Notice
COBRA model election notice 5 1 14 230pm.docx Other-COBRA Model Election Notice
ModelGeneralNoticeSP.doc Other-COBRA Model General Notice Spa
ModelElectionNoticeSP.doc Other-COBRA Model Election Notice Sp

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Notice Requirements of the Health Care Continuation Coverage Provisions	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 2590

Information Collection Instruments:

Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-COBRA Model General Notice	modelgeneralnotice 5 1 14 230pm.doc	Yes	No	Fillable Printable
Other-COBRA Model Election Notice	COBRA model election notice 5 1 14 230pm.docx	Yes	No	Fillable Printable
Other-COBRA Model General Notice Spanish	ModelGeneralNoticeSP.doc	Yes	No	Fillable Printable
Other-COBRA Model Election Notice Spanish	ModelElectionNoticeSP.doc	Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 660,653	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	18,128,968	2,076,473	16,052,495
Annual IC Time Burden (Hours)	0	0	0
Annual IC Cost Burden (Dollars)	37,133,409	6,642,511	30,490,898

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.