Health Benefits Election Form

Forms and Documents

Document Name	Status
Form SF 2809 Health Benefits Election Form Form and Instruction	Unchanged
SF2809_2015_11 markup_2015_11_02.pdf Supplementary Document	2016-02-10
SF2809_30-DayFRN_Publication_2015_10_23.pdf Supplementary Document	2015-10-30
SF2809_60Day_Published.pdf Supplementary Document	2015-10-30
SF2809_OMB_Supporting_Statement-082515.doc Supporting Statement A	2015-10-30

IC Document Collections

IC ID	Document Title	Status
33632	Health Benefits Election Form Form and Instruction	Unchanged

ICR Details

OMB Control No: 3206-0160	ICR Reference No: 201510-3206-008
Status: Historical Active	Previous ICR Reference No: 201408-3206-004
Agency/Subagency: OPM	Agency Tracking No:
Title: Health Benefits Election Form
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 02/18/2016
	Date Received in OIRA: 10/30/2015
Terms of Clearance: This collection is approved based on the revised materials provided by the Agency.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2019	36 Months From Approved	10/31/2017
Responses	18,000	0	18,000
Time Burden (Hours)	9,000	0	9,000
Cost Burden (Dollars)	0	0	0

---

Abstract: SF 2809, Health Benefits Election Form, is used by Federal employees, annuitants other than those under the Civil Service Retirement System (CSRS) and the Federal Employees Retirement System (FERS) including individuals receiving benefits from the Office of Workers' Compensation Programs, former spouses eligible for benefits under the Spouse Equity Act of 1984, and separated employees and former dependents eligible to enroll under the Temporary Continuation of Coverage provisions of the FEHB law (5 U.S.C. 8905a). A different form (OPM 2809) is used by CSRS and FERS annuitants whose health benefit enrollments are administered by OPM's Retirement Operations. The form was revised to bring the web sites up to date. The FEHB added the self-plus one option for the 2016 year.

---

Authorizing Statute(s): US Code: 5 USC 8905a Name of Law: Continued Coverage
   PL: Pub.L. 98 - 615 CSRS Name of Law: Spouse Equity Act of 1984
   US Code: 5 USC 89 Name of Law: Health Insurance
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 32994	06/10/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 64454	10/23/2015
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Health Benefits Election Form	SF 2809	Health Benefits Election Form

---

ICR Summary 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	18,000	18,000	0	0	0	0
Annual Time Burden (Hours)	9,000	9,000	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $16,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 10/30/2015

---