Information Collection

HRA Notice to Participants and other disclosures

IC 233410 under ICR 202204-1210-003 · OMB 1210-0160.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1210-0160 can be found here:

Documents and Forms

Document Name Document Type
HRA Model Notice FINAL.pdf www.dol.gov/sites/default/files/ebsa/laws-and-regulations/rules-and-regulations/completed-rulemaking/1210-AB87/individua Other-Model
HRA Model Notice FINAL.pdf www.dol.gov/sites/default/files/ebsa/laws-and-regulations/rules-and-regulations/completed-rulemaking/1210-AB87/individua Other-Model
HRA Model Attestation FINAL.pdf www.dol.gov/sites/default/files/ebsa/laws-and-regulations/rules-and-regulations/completed-rulemaking/1210-AB87/individua Other-Model
HRA Model Attestation FINAL.pdf www.dol.gov/sites/default/files/ebsa/laws-and-regulations/rules-and-regulations/completed-rulemaking/1210-AB87/individua Other-Model

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	HRA Notice to Participants and other disclosures	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 29 CFR 2590.702-2

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Model			HRA Model Notice FINAL.pdf	https://www.dol.gov/sites/default/files/ebsa/laws-and-regulations/rules-and-regulations/completed-rulemaking/1210-AB87/individual-coverage-model-notice.pdf	Yes	Yes	Printable Only
Other-Model			HRA Model Attestation FINAL.pdf	https://www.dol.gov/sites/default/files/ebsa/laws-and-regulations/rules-and-regulations/completed-rulemaking/1210-AB87/individual-coverage-model-attestation.pdf	Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 165,897	Number of Respondents for Small Entity: 159,261

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

Percentage of Respondents Reporting Electronically: 58 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,128,613	-7,270,815	9,399,428
Annual IC Time Burden (Hours)	52,166	-144,826	196,992
Annual IC Cost Burden (Dollars)	24,831	-95,831	120,662

Documents for IC

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.