Health Benefits Election Form

OPM 2809, Health Benefits Election Form

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.