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Notice to Employee of Pending Cancellation of Health Benefits (State, local, tribal)
The Family and Medical Leave Act of 1993, As Amended
OMB: 1235-0003
IC ID: 186900
OMB.report
DOL/WHD
OMB 1235-0003
ICR 202306-1235-001
IC 186900
( )
Documents and Forms
Document Name
Document Type
no available documents/forms check other ICs listed under this ICR
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Notice to Employee of Pending Cancellation of Health Benefits (State, local, tribal)
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Unchanged
Obligation to Respond:
Mandatory
CFR Citation:
29 CFR 825.212(a)
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Federal Enterprise Architecture Business Reference Module
Line of Business:
Workforce Management
Subfunction:
Labor Rights Management
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
50,866
Number of Respondents for Small Entity:
35,244
Affected Public:
State, Local, and Tribal Governments
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
50,866
0
0
0
0
50,866
Annual IC Time Burden (Hours)
4,239
0
0
0
0
4,239
Annual IC Cost Burden (Dollars)
0
0
0
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.