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Federal forms, ICRs, and supporting documents

Information Collection

HRA Notice to Participants and Other Disclosures

IC 233410 under ICR 202503-1210-003 · OMB 1210-0160.

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

View Information Collection (IC)

HRA Notice to Participants and Other Disclosures
 
No Modified
 
Mandatory
 
29 CFR 2590.702-2

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Model HRA Model Notice FINAL.pdf https://www.dol.gov/sites/default/files/ebsa/laws-and-regulations/rules-and-regulations/completed-rulemaking/1210-AB87/individual-coverage-model-notice.pdf Yes Yes Printable Only
Other-Model HRA Model Attestation FINAL.pdf https://www.dol.gov/sites/default/files/ebsa/laws-and-regulations/rules-and-regulations/completed-rulemaking/1210-AB87/individual-coverage-model-attestation.pdf Yes Yes Printable Only

Health Health Care Services

 

123,738 123,614
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   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 1,407,453 0 0 -721,160 0 2,128,613
Annual IC Time Burden (Hours) 31,399 0 0 -20,767 0 52,166
Annual IC Cost Burden (Dollars) 16,996 0 0 -7,835 0 24,831

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