View Information Collection (IC)

View Information Collection (IC)

IC Title:	Notice to Employees of Coverage Options Under FLSA Section 18B (State and Local Gov't)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Model Notice			model-notice-for-employers-who-offer-a-health-plan-to-some-or-all-employees 8.29 (clean).docx		Yes	No	Printable Only
Other-Model Notice			model-notice-for-employers-who-do-not-offer-a-health-plan 8.29 (clean).docx		Yes	No	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 302,663	Number of Respondents for Small Entity: 292,567

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 58 %

	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	4,628,623	0	0	320,499	0	4,308,124
Annual IC Time Burden (Hours)	38,572	0	0	22,932	0	15,640
Annual IC Cost Burden (Dollars)	802,927	0	0	99,113	0	703,814

Documents for IC

Title	Document	Date Uploaded
Instructions	DOL TR 2013-02.pdf	04/10/2023

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