Model Employer CHIP Notice (Private Sector Burden)

Model Employer Children's Health Insurance Program Notice

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1210-0137 can be found here:

Documents and Forms

Document Name Document Type
chipmodelnotice 4 28 14 for ROCIS.doc Other-Model Notice

Information Collection (IC) Details

IC Title:	Model Employer CHIP Notice (Private Sector Burden)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Model Notice			chipmodelnotice 4 28 14 for ROCIS.doc		Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,961,000	Number of Respondents for Small Entity: 38

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

Percentage of Respondents Reporting Electronically: 38 %

	Approved	Previously Approved
Annual Number of Responses for this IC	174,347,154	174,347,154
Annual IC Time Burden (Hours)	900,519	900,519
Annual IC Cost Burden (Dollars)	21,619,363	21,619,363

Documents for IC

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.