Information Collection

Self-Certification or Notification

IC 205659 under ICR 202108-1210-009 · OMB 1210-0150.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1210-0150 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-10653 Model Notice to HHS_clean.docx	Other-Model Notice
CMS-10653 Model Notice to HHS_clean.docx	Other-Model Notice
EBSA Form 700 Eligible Organization Self-Certification CMS-10653 Certification_clean.docx www.dol.gov/ebsa/pdf/preventiveserviceseligibleorganizationcertificationform.pdf	Form
EBSA Form 700 Eligible Organization Self-Certification CMS-10653 Certification_clean.docx www.dol.gov/ebsa/pdf/preventiveserviceseligibleorganizationcertificationform.pdf	Form

IC Title:

Self-Certification or Notification

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 29 CFR 2510.3-16 29 CFR 2590.715-2713A

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			CMS-10653 Model Notice to HHS_clean.docx		Yes	Yes	Printable Only
Form	EBSA Form 700	Eligible Organization Self-Certification	CMS-10653 Certification_clean.docx	http://www.dol.gov/ebsa/pdf/preventiveserviceseligibleorganizationcertificationform.pdf	Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 58 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	5	0	5
Annual IC Time Burden (Hours)	4	0	4
Annual IC Cost Burden (Dollars)	2	1	1

Documents for IC

table that charts IC Documents
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.