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

Documents and Forms
Information Collection (IC) Details

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Notice to Employees of Coverage Options Under FLSA Section 18B (State and Local Gov't)
 
No Modified
 
Mandatory
 

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

Health Consumer Health and Safety

 

302,663 292,567
   
State, Local, and Tribal Governments
 
   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

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.

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