Notice to Employee of Pending Cancellation of Health Benefits (State, local, tribal)

29 C.F.R. Part 825, The Family and Medical Leave Act of 1993

Documents and Forms

Document Name Document Type

no available documents/forms check other ICs listed under this ICR

Information Collection (IC) Details

IC Title:	Notice to Employee of Pending Cancellation of Health Benefits (State, local, tribal)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 29 CFR 825.212(a)

Information Collection 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: 37,000	Number of Respondents for Small Entity: 35,244

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	37,000	7,473	29,527
Annual IC Time Burden (Hours)	3,083	623	2,460
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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