Establishing Creditable Coverage

ICR 200412-1210-003

OMB: 1210-0103

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
38420
Migrated
ICR Details
1210-0103 200412-1210-003
Historical Active 200306-1210-007
DOL/EBSA
Establishing Creditable Coverage
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 12/30/2004
Retrieve Notice of Action (NOA) 12/30/2004
  Inventory as of this Action Requested Previously Approved
10/31/2006 10/31/2006 10/31/2006
21,000,000 0 44,396,000
260,000 0 351,150
18,500,000 0 34,689,000

Pursuant to implementing rules at 29 CFR 2590.701-5, this ICR describes the provisions for group health plans to provide information to participants that will be sufficient to establish prior creditable coverage.

None
None


No

1
IC Title Form No. Form Name
Establishing Creditable Coverage

  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 21,000,000 44,396,000 0 0 -23,396,000 0
Annual Time Burden (Hours) 260,000 351,150 0 0 -91,150 0
Annual Cost Burden (Dollars) 18,500,000 34,689,000 0 0 -16,189,000 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.
12/30/2004


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