Information Collection

Employer Notification Request to HHS of its Objection to Providing Contraceptive Services – Self-Certification

IC 212753 under ICR 201503-0938-004 · OMB 0938-1248.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-10535 Model Notice.pdf Model Notice	IC Document

IC Title:

Employer Notification Request to HHS of its Objection to Providing Contraceptive Services â Self-Certification

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 147.131(b)(4) 45 CFR 147.131(c)(1)

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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 61

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	61	-61	122
Annual IC Time Burden (Hours)	51	-59	110
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Model Notice	CMS-10535 Model Notice.pdf	03/06/2015

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