Information Collection

Notice to Employees of Coverage Options Under FLSA 18B (Private Sector)

IC 206431 under ICR 202002-1210-005 · OMB 1210-0149.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1210-0149 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
model-notice-for-employers-who-offer-a-health-plan-to-some-or-all-employees.pdf	Other-Model Notice
DOL TR 2013-02.pdf Technical Release 2013-02	IC Document

IC Title:

Notice to Employees of Coverage Options Under FLSA 18B (Private Sector)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

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
Other-Model Notice			model-notice-for-employers-who-offer-a-health-plan-to-some-or-all-employees.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,760,000

Number of Respondents for Small Entity: 5,980,300

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Farms, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 56 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	27,760,144	2,514,616	25,245,528
Annual IC Time Burden (Hours)	100,781	-622	101,403
Annual IC Cost Burden (Dollars)	4,535,150	458,755	4,076,395

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Technical Release 2013-02	DOL TR 2013-02.pdf	11/06/2013

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