Information Collection

Notice of Eligibility

IC 280372 under ICR 202605-1210-001 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Notice.docx	Other-Other

IC Title:

Agency IC Tracking Number:

Is this a Common Form? Yes

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 29 CFR 2590

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-Other					No		Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 490,266

Number of Respondents for Small Entity: 404,080

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 58 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	17,868,973	17,868,973
Annual IC Time Burden (Hours)	270	270
Annual IC Cost Burden (Dollars)	446,704	446,704

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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