Information Collection

Self-Certification

IC 205659 under ICR 201302-1210-002 · OMB 1210-0150.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1210-0150 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form EBSA700 Self-Certification	Form
EBSA700 Preventive Health Services Certification Preventive Service Certification 1-30-13.docx	Form

IC Title:

Self-Certification

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 29 CFR 2590

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	EBSA700	Preventive Health Services Certification	Preventive Service Certification 1-30-13.docx	xxx	Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Certification

FR Citation: 78 FR 8833

Number of Respondents: 1

Number of Respondents for Small Entity: 1

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1	1
Annual IC Time Burden (Hours)	1	1
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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