View Information Collection (IC)

View Information Collection (IC)

IC Title:	Self-Certification or Notification	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 29 CFR 2510.3-16 29 CFR 2590.715-2713A

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Model Notice			DOL Model Notice to HHS 4-13-18.docx		Yes	Yes	Printable Only
Form	EBSA Form 700	Eligible Organization Self-Certification	EBSA Form 700 Certification 4-11-18.docx	http://www.dol.gov/ebsa/pdf/preventiveserviceseligibleorganizationcertificationform.pdf	Yes	No	Printable Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 50 %

	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	5	0	0	0	0	5
Annual IC Time Burden (Hours)	4	0	0	0	0	4
Annual IC Cost Burden (Dollars)	1	0	0	0	0	1

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.