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Extended Benefit Data
EXTENDED BENEFIT DATA
OMB: 1205-0028
IC ID: 120612
OMB.report
DOL/ETA
OMB 1205-0028
ICR 198009-1205-010
IC 120612
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1205-0028 can be found here:
2022-08-30 - Extension without change of a currently approved collection
2019-09-23 - Extension without change of a currently approved collection
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:
EXTENDED BENEFIT DATA
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Migrated
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
Form
ETA 5-39
No
No
Federal Enterprise Architecture Business Reference Module
Line of Business:
Subfunction:
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
53
Number of Respondents for Small Entity:
0
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
2,756
0
0
0
0
2,756
Annual IC Time Burden (Hours)
2,067
0
0
0
0
2,067
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.