Information Collection

Open Season Health Benefits Enrollment Change Form

IC 33686 under ICR 199610-3206-004 · OMB 3206-0200.

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

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

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-EZ2				Yes	Yes

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 35,345

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 18 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	35,345	35,345
Annual IC Time Burden (Hours)	17,672	17,672
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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Title	Document	Date Uploaded

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