OPEN SEASON HEALTH BENEFITS ENROLLMENT CHANGE

ICR 199407-3206-004

OMB: 3206-0200

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
157092 Migrated
ICR Details
3206-0200 199407-3206-004
Historical Active 199308-3206-001
OPM
OPEN SEASON HEALTH BENEFITS ENROLLMENT CHANGE
Revision of a currently approved collection   No
Regular
Approved without change 10/14/1994
Retrieve Notice of Action (NOA) 07/26/1994
  Inventory as of this Action Requested Previously Approved
10/31/1995 10/31/1995 10/31/1994
35,559 0 38,315
18,280 0 19,158
0 0 0

OPM FORM 2809-EZ2 IS USED ONLY AT OPEN SEASON TO ELECT A CHANGE IN HEALTH BENEFIT COVERAGE. IT IS COMPLETED BY RETIREES, SURVIVOR ANNUITANTS, AND FORMER SPOUSES OF RETIREES WHO HAVE PREVIOUSLY REQUESTED INFORMATION ON AVAILABLE PLANS BY COMPLETING OPM 2809-E21.

None
None


No

1
IC Title Form No. Form Name
OPEN SEASON HEALTH BENEFITS ENROLLMENT CHANGE OPM 2809-EZ2

  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 35,559 38,315 0 0 -2,756 0
Annual Time Burden (Hours) 18,280 19,158 0 0 -878 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
07/26/1994


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