OMB
.report
Search
Notice to Employees of Coverage Options Under FLSA Section 18B (State and Local Gov't)
Notice to Employees of Coverage Options Under Fair Labor Standards Act Section 18B
OMB: 1210-0149
IC ID: 225307
OMB.report
DOL/EBSA
OMB 1210-0149
ICR 202301-1210-003
IC 225307
( )
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
Instructions
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Notice to Employees of Coverage Options Under FLSA Section 18B (State and Local Gov't)
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
Printable Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Consumer Health and Safety
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
302,663
Number of Respondents for Small Entity:
292,567
Affected Public:
State, Local, and Tribal Governments
Percentage of Respondents Reporting Electronically:
58 %
Requested
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
4,628,623
0
0
320,499
0
4,308,124
Annual IC Time Burden (Hours)
38,572
0
0
22,932
0
15,640
Annual IC Cost Burden (Dollars)
802,927
0
0
99,113
0
703,814
Documents for IC
Title
Document
Date Uploaded
Instructions
DOL TR 2013-02.pdf
04/10/2023
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.