Information Collection

Notice to Employees of Coverage Options Under FLSA 18B (Private Sector)

IC 206431 under ICR 202301-1210-003 · OMB 1210-0149.

Documents and Forms

Document Name Document Type
model-notice-for-employers-who-offer-a-health-plan-to-some-or-all-employees.pdf Other-Model Notice
DOL TR 2013-02.pdf Instructions IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Notice to Employees of Coverage Options Under FLSA 18B (Private Sector)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Model Notice			model-notice-for-employers-who-offer-a-health-plan-to-some-or-all-employees.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10,606,413	Number of Respondents for Small Entity: 10,252,610

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

Percentage of Respondents Reporting Electronically: 58 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	26,966,621	-793,523	27,760,144
Annual IC Time Burden (Hours)	224,722	123,941	100,781
Annual IC Cost Burden (Dollars)	4,677,900	142,750	4,535,150

Documents for IC

Title	Document	Date Uploaded
Instructions	DOL TR 2013-02.pdf	04/10/2023

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.