Information Collection

Notice to Employee of Pending Cancellation of Health Benefits (Private Sector)

IC 182234 under ICR 202605-1235-003 · OMB 1235-0003.

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Information Collection (IC) Details

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IC Title:	Notice to Employee of Pending Cancellation of Health Benefits (Private Sector)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 29 CFR 825.212(a)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Workforce Management

Subfunction: Labor Rights Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 130,956	Number of Respondents for Small Entity: 97,062

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Farms, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	130,956	-14,196	145,152
Annual IC Time Burden (Hours)	10,913	-1,183	12,096
Annual IC Cost Burden (Dollars)	0	0	0

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