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Notice of Revocation of Accommodation
Coverage of Certain Preventive Services under the Affordable Care Act—Private Sector
OMB: 1210-0150
IC ID: 228285
OMB.report
DOL/EBSA
OMB 1210-0150
ICR 201710-1210-001
IC 228285
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1210-0150 can be found here:
2023-02-02 - Revision of a currently approved collection
2021-09-28 - Extension without change of a currently approved collection
Documents and Forms
Document Name
Document Type
no available documents/forms check other ICs listed under this ICR
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Notice of Revocation of Accommodation
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
New
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
29 CFR 2510.3-16
29 CFR 2590.715-2713A
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
109
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits, Not-for-profit institutions
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
64,379
0
64,379
0
0
0
Annual IC Time Burden (Hours)
109
0
109
0
0
0
Annual IC Cost Burden (Dollars)
16,096
0
16,096
0
0
0
Documents for IC
Title
Document
Date Uploaded
No associated records found
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.