Information Collection Request

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

ICR 202108-1210-009 · OMB 1210-0150 · Received in OIRA

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
SS 1210-0150 6-15-21 (clean) 9.28.21.docx Supporting Statement A Uploaded 2021-09-28 Repair queued
30-day FRN (1210-0150) published.pdf Supplementary Document Uploaded 2021-09-28 Missing upstream
60-day FRN (1210-0150) published.pdf Supplementary Document Uploaded 2021-09-27 Repair queued

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
  Requested Previously Approved
36 Months From Approved 11/30/2021
777,363 777,363
181 181
194,963 197,955





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

table that charts list of burden
  Total Request 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 777,363 777,363 0 0 0 0
Annual Time Burden (Hours) 181 181 0 0 0 0
Annual Cost Burden (Dollars) 194,963 197,955 0 0 -2,992 0


Reginfo record details
  No