Model Employer CHIP Notice (State, Local, Tribal Governmental Burden)

Model Employer Children's Health Insurance Program Notice

OMB: 1210-0137

IC ID: 208807

Documents and Forms
Document Name
Document Type
Other-Model Notice
Other-Model Notice
Other-Model Notice Spanish
Other-Model Notice Spanish
Information Collection (IC) Details

View Information Collection (IC)

Model Employer CHIP Notice (State, Local, Tribal Governmental Burden)
 
No Modified
 
Mandatory
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Model Notice model-notice.docx https://www.dol.gov/sites/dolgov/files/EBSA/laws-and-regulations/laws/chipra/model-notice.doc Yes No Fillable Printable
Other-Model Notice Spanish model-notice-spanish.docx https://www.dol.gov/sites/dolgov/files/EBSA/laws-and-regulations/laws/chipra/model-notice-spanish.doc Yes No Fillable Printable

Income Security General Retirement and Disability

 

75,436 0
   
State, Local, and Tribal Governments
 
   58 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 15,255,939 0 0 1,706,019 0 13,549,920
Annual IC Time Burden (Hours) 53,142 0 0 3,950 0 49,192
Annual IC Cost Burden (Dollars) 1,275,397 0 0 94,793 0 1,180,604

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