Information Collection

Open Season Health Benefits Enrollment Change Form Or Request For Additional Information

IC 157094 under ICR 199108-3206-002 · OMB 3206-0201.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3206-0201 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

OPEN SEASON HEALTH BENEFITS ENROLLMENT CHANGE FORM OR REQUEST FOR ADDITIONAL INFORMATION

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Migrated

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	OPM 2809-EZ1				No	No

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 127,913

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	127,913	127,913
Annual IC Time Burden (Hours)	63,957	63,957
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.