Skip to main content
An official website of the United States government
The .gov means it's official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.
The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.
Search:
Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Self-Certification
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
New
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
29 CFR 2590
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
EBSA700
Preventive Health Services Certification
Preventive Service Certification 1-30-13.docx
xxx
Yes
No
Printable Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
Certification
FR Citation:
78 FR 8833
Number of Respondents:
1
Number of Respondents for Small Entity:
1
Affected Public:
Private Sector
Private Sector:
Not-for-profit institutions
Percentage of Respondents Reporting Electronically:
50 %
Requested
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
0
1
0
0
0
Annual IC Time Burden (Hours)
1
0
1
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
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.
An official website of the United States government
The .gov means it's official.
The site is secure.
