Notice to Employees of Coverage Options Under FLSA 18B (Private Sector)

Notice to Employees of Coverage Options Under Fair Labor Standards Act Section 18B

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1210-0149 can be found here:

Documents and Forms

Document Name Document Type
model-notice-for-employers-who-offer-a-health-plan-to-some-or-all-employees.pdf Other-Model Notice
DOL TR 2013-02.pdf Technical Release 2013-02 IC Document

Information Collection (IC) Details

IC Title:	Notice to Employees of Coverage Options Under FLSA 18B (Private Sector)	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			model-notice-for-employers-who-offer-a-health-plan-to-some-or-all-employees.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 7,760,000	Number of Respondents for Small Entity: 5,980,300

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

Percentage of Respondents Reporting Electronically: 56 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	27,760,144	2,514,616	25,245,528
Annual IC Time Burden (Hours)	100,781	-622	101,403
Annual IC Cost Burden (Dollars)	4,535,150	458,755	4,076,395

Documents for IC

Title	Document	Date Uploaded
Technical Release 2013-02	DOL TR 2013-02.pdf	11/06/2013

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.