Information Collection

Health Benefits Election Form

IC 33609 under ICR 201603-3206-001 · OMB 3206-0141.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3206-0141 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form OPM Form 2809 Health Benefits Election Form	Form and Instruction
OPM Form 2809 Health Benefits Election Form OPM2809_2015_11_MarkUp.pdf www.opm.gov/forms/pdf_fill/opm2809.pdf	Form and Instruction
OPM2809_OMBSupportingStatement_2015.doc OPM2809_OMB Supporting Statement	IC Document
OPM2809_30DayFRNPublished_2015_11_20.pdf OPM2809_30 Day Federal Register Notice	IC Document
OPM2809_60DayFRNPublished_2015_07_08.pdf OPM2809_60-Day Federal Register Notice	IC Document

IC Title:

Health Benefits Election Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 5 CFR Ch. 1, Part 890.301 thru 307 (To search for a specific CFR, visit the Code of Federal Regulations.)

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
Form and Instruction	OPM Form 2809	Health Benefits Election Form	OPM2809_2015_11_MarkUp.pdf	https://www.opm.gov/forms/pdf_fill/opm2809.pdf	Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Executive Functions

Privacy Act System of Records

Title: OPM/Central-1

FR Citation: 73 FR 15013

Number of Respondents: 30,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	30,000	30,000
Annual IC Time Burden (Hours)	11,667	11,667
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
OPM2809_OMB Supporting Statement	OPM2809_OMBSupportingStatement_2015.doc	03/02/2016
OPM2809_30 Day Federal Register Notice	OPM2809_30DayFRNPublished_2015_11_20.pdf	03/02/2016
OPM2809_60-Day Federal Register Notice	OPM2809_60DayFRNPublished_2015_07_08.pdf	03/02/2016

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