Information Collection

Self-Certification or Notiffication

IC 205659 under ICR 201408-1210-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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

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Information Collection (IC) Details

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IC Title:	Self-Certification or Notiffication	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 29 CFR 2510 29 CFR 2590

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 122	Number of Respondents for Small Entity: 120

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

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	122	1	119	2
Annual IC Time Burden (Hours)	51	1	48	2
Annual IC Cost Burden (Dollars)	33	0	32	1

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.