Information Collection

Notice to Employees of Coverage Options Under FLSA Section 18B (State and Local Gov't)

IC 225307 under ICR 202301-1210-003 · OMB 1210-0149.

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of 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	Printable Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 302,663

Number of Respondents for Small Entity: 292,567

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 58 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	4,628,623	320,499	4,308,124
Annual IC Time Burden (Hours)	38,572	22,932	15,640
Annual IC Cost Burden (Dollars)	802,927	99,113	703,814

Documents for IC

table that charts IC Documents
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.