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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1235-0003 can be found here:

Documents and Forms

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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: Unchanged

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	Previously Approved
Annual Number of Responses for this IC	37,000	37,000
Annual IC Time Burden (Hours)	3,083	3,083
Annual IC Cost Burden (Dollars)	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.