Information Collection

Notice to Employees of Coverage Options Under FLSA Section 18B (State and Local Gov't)

IC 225307 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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Notice to Employees of Coverage Options Under FLSA Section 18B (State and Local Gov't)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection 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	Printable Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 90,126	Number of Respondents for Small Entity: 72,800

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 56 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	4,308,124	387,812	3,920,312
Annual IC Time Burden (Hours)	15,640	-106	15,746
Annual IC Cost Burden (Dollars)	703,814	70,801	633,013

Documents for IC

Title	Document	Date Uploaded
Technical Release 2013-02	DOL TR 2013-02.pdf	01/25/2017

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