Information Collection

Notice to Employee of Pending Cancellation of Health Benefits (Private Sector)

IC 182234 under ICR 200810-1215-003 · OMB 1215-0181.

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IC Title:

Notice to Employee of Pending Cancellation of Health Benefits (Private Sector)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 29 CFR 825.212(a)

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

Line of Business: Workforce Management

Subfunction: Labor Rights Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 105,585

Number of Respondents for Small Entity: 97,062

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Farms, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to New Statute	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	105,585	2,138	103,447
Annual IC Time Burden (Hours)	8,799	1,777	7,022
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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