Information Collection Request

Coverage of Certain Preventive Services under the Affordable Care Act—Private Sector

ICR 202407-1210-002 · OMB 1210-0150 · Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form EBSA Form 700 Eligible Organization Self-Certification Form Modified Available
Contraceptive SS 1210-0150 9-4-24 (clean).docx Supporting Statement A Uploaded 2024-09-16 Available
30-day FRN (1210-0150) published.pdf Supplementary Document Uploaded 2021-09-28 Repair queued
60-day FRN (1210-0150) published.pdf Supplementary Document Uploaded 2021-09-27 Repair queued

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
228285 Notice of Revocation of Accommodation Removed
228284 Notice of Availability of Separate Payments for Contraceptive Services Other-Model Modified
205659 Self-Certification or Notification Form ModifiedEligible Organization Self-Certification
205659 Self-Certification or Notification Other-Model Notice Modified

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
01/31/2028 36 Months From Approved 01/31/2025
595,312 0 777,363
72 0 181
181,222 0 194,963





Reginfo record details
2
table that charts list of burden
IC Title Form No. Form Name
Notice of Availability of Separate Payments for Contraceptive Services
Notice of Revocation of Accommodation
Self-Certification or Notification EBSA Form 700

table that charts list of burden
  Total Approved 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 595,312 777,363 0 0 -182,051 0
Annual Time Burden (Hours) 72 181 0 0 -109 0
Annual Cost Burden (Dollars) 181,222 194,963 0 0 -13,741 0


Reginfo record details
  No