Health Benefits Election Form

ICR 202204-3206-001

OMB: 3206-0160

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Supporting Statement A
2022-05-05
Supplementary Document
2022-05-04
Justification for No Material/Nonsubstantive Change
2022-03-07
Supplementary Document
2022-04-28
Supplementary Document
2022-04-28
Supplementary Document
2022-04-28
IC Document Collections
IC ID
Document
Title
Status
33632 Modified
ICR Details
3206-0160 202204-3206-001
Received in OIRA 202203-3206-004
OPM SF 2809
Health Benefits Election Form
Revision of a currently approved collection   No
Regular 05/05/2022
  Requested Previously Approved
36 Months From Approved 05/31/2022
18,000 18,000
9,000 9,000
0 0

The SF 2809 is used by Federal employees, annuitants other than those under the Civil Service Retirement System (CSRS) and the Federal Employees Retirement System (FERS) including individuals receiving benefits from the Office of Workers' Compensation Programs, former spouses eligible for benefits under the Spouse Equity Act of 1984 (P.L. 98-615), and separated employees and former dependents eligible to enroll under the Temporary Continuation of Coverage (TCC) provisions of the FEHB law (5 U.S.C. 8905a). A different form (OPM 2809) is used by CSRS and FERS annuitants whose health benefit enrollments are administered by OPM's Retirement Services Program. The Privacy Act Statement has been revised due to a general systematic review by our Chief Privacy Officer.

US Code: 5 USC 8905a Name of Law: Continued Coverage
   US Code: 5 USC 89 Name of Law: Health Insurance
   PL: Pub.L. 98 - 615 CSRS Name of Law: Spouse Equity Act of 1984
  
None

Not associated with rulemaking

  86 FR 60304 11/01/2021
87 FR 26237 05/03/2022
No

1
IC Title Form No. Form Name
Health Benefits Election Form SF 2809 Health Benefits Election Form

  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 18,000 18,000 0 0 0 0
Annual Time Burden (Hours) 9,000 9,000 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 -242,999 242,999 0
No
No

$16,000
No
    Yes
    Yes
Yes
No
No
Yes
Charles Conyers 202 606-0125 [email protected]

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
05/05/2022


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