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

Notice to Employees of Coverage Options Under Fair Labor Standards Act Section 18B

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

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.