Information Collection Request

Coverage of Certain Preventive Services Under the Affordable Care Act

ICR 201408-1210-005 · OMB 1210-0150 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
WheatonemergencyPRArequest.doc Supplementary Document Uploaded 2014-08-07 Available
Form 700 IFR supporting statement 8 20 14.docx Supporting Statement A Uploaded 2014-08-20 Available

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
205659 Self-Certification or Notiffication Other-Model Notice Modified

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
02/28/2015 6 Months From Approved 08/31/2016
122 0 2
51 0 2
33 0 1





Reginfo record details
1
table that charts list of burden
IC Title Form No. Form Name
Self-Certification or Notiffication EBSA Form 700 Eligible Organization Self-Certification

table that charts list of burden
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 122 2 0 1 119 0
Annual Time Burden (Hours) 51 2 0 1 48 0
Annual Cost Burden (Dollars) 33 1 0 0 32 0


Reginfo record details
  No