OPM 2809-HEALTH BENEFITS REGISTRATION FORM, OPM 2809 EZ-1, 2 HEALTH BENEFITS ENROLLMENT CHANGE FORM, DPRS 2809, REQUEST TO CHANGE FEHB ENROLLMENT OR TO RECEIVE PLAN BROCHURES FOR..

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability

No forms / supporting documents in this ICR. Check IC Document Collections.

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
156941	OPM 2809-HEALTH BENEFITS REGISTRATION FORM, OPM 2809 EZ-1, 2 HEALTH BENEFITS ENROLLMENT CHANGE FORM, DPRS 2809, REQUEST TO CHANGE FEHB ENROLLMENT OR TO RECEIVE PLAN BROCHURES FOR..	Form	Migrated

ICR Details

OMB Control No: 3206-0141	ICR Reference No: 199011-3206-001
Status: Historical Active	Previous ICR Reference No: 199008-3206-007
Agency/Subagency: OPM	Agency Tracking No:
Title: OPM 2809-HEALTH BENEFITS REGISTRATION FORM, OPM 2809 EZ-1, 2 HEALTH BENEFITS ENROLLMENT CHANGE FORM, DPRS 2809, REQUEST TO CHANGE FEHB ENROLLMENT OR TO RECEIVE PLAN BROCHURES FOR..
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/05/1990
	Date Received in OIRA: 11/23/1990
Terms of Clearance: 1. This action by OMB adds to the existing approval under OMB control number 3206-0141, the DPRS Form 2809 and its instructions. 2. This action changes the expiration date for all forms approved under this control number to June 1991. 3. This change in the expiration date is made because of the large amount of public comment being received at OMB during the current open season regarding the confusing nature of the instructions. Specifically, individuals receiving open season material have complained about the burden associated with understanding the form due to a lack of clarity regarding what to do if no change in health benefit plan is desired. Representative letters received by OMB on this subject are being forwarded to Ron Trueworthy of OPM under seperate cover. 4. In its next request for approval of these forms, prior to the next open season, OPM should demonstrate responsiveness to the complaints described above by making modifications to the draft open season material submitted for OPM approval.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/1991	06/30/1991	06/30/1992
Responses	295,500	0	285,500
Time Burden (Hours)	147,750	0	142,750
Cost Burden (Dollars)	0	0	0

---

Abstract: OPM 2809 IS USED TO ELECT, CANCEL OR CHANGE HEALTH BENEFITS DURING PERIODS OTHER THAN OPEN SEASON. OPM 2809 EZ-1, 2 ARE USED BY ANNUITANT AND SURVIVOR ANNUITANTS WHO CHOOSE TO CHANGE HEALTH BENEFITS DURING OPEN SEASON. DPRS 2809 IS USED BY FORMER SPOUSE AND TEMPORARY CONTINUATION OF COVERAGE ENROLLEES, DURING OPEN SEASON, TO CHANGE FEHB

---

Authorizing Statute(s): None

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:

---

Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
OPM 2809-HEALTH BENEFITS REGISTRATION FORM, OPM 2809 EZ-1, 2 HEALTH BENEFITS ENROLLMENT CHANGE FORM, DPRS 2809, REQUEST TO CHANGE FEHB ENROLLMENT OR TO RECEIVE PLAN BROCHURES FOR..	OPM 2809, 2809 EZ-1, 2, DPRS 2809

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	295,500	285,500	0	10,000	0	0
Annual Time Burden (Hours)	147,750	142,750	0	5,000	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 11/23/1990

---