Information Collection Request

Coverage of Certain Preventive Services under the Affordable Care Act—Private Sector

ICR 201803-1210-001 · OMB 1210-0150 · Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
SS 1210-0150 10-24-18.docx Supporting Statement A Uploaded 2018-10-24 Available

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
228285 Notice of Revocation of Accommodation Modified
228284 Notice of Availability of Separate Payments for Contraceptive Services Other-Model Modified
205659 Self-Certification or Notification Other-Model Notice Modified

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
11/30/2021 36 Months From Approved 11/30/2018
777,363 0 274,629
181 0 181
197,955 0 68,662





Reginfo record details
3
table that charts list of burden
IC Title Form No. Form Name
Self-Certification or Notification EBSA Form 700 Eligible Organization Self-Certification
Notice of Availability of Separate Payments for Contraceptive Services
Notice of Revocation of Accommodation

table that charts list 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 777,363 274,629 0 502,734 0 0
Annual Time Burden (Hours) 181 181 0 0 0 0
Annual Cost Burden (Dollars) 197,955 68,662 0 129,293 0 0


Reginfo record details
  No