Information Collection

Web-based Health/Benefit Enrollment

IC 222952 under ICR 202512-0702-002 · OMB 0702-0139.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
eBenefit Screens (Web-Based Collection).pdf	Other-Website
0702-0139_E-BENEFITS ONLINE ENROLLMENT_trimmed.pdf	Other-Website

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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-Website					Yes	Yes	Fillable Fileable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 9,960

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	9,960	0	9,960
Annual IC Time Burden (Hours)	3,320	0	3,320
Annual IC Cost Burden (Dollars)	128,916	13,015	115,901

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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

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