View Information Collection (IC)

View Information Collection (IC)

Notice to Employees of Coverage Options Under FLSA Section 18B (State and Local Gov't)
No Modified

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.pdf Yes No Printable Only

Health Consumer Health and Safety


90,126 72,800
State, Local, and Tribal Governments
   56 %

  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 4,308,124 0 0 387,812 0 3,920,312
Annual IC Time Burden (Hours) 15,640 0 0 -106 0 15,746
Annual IC Cost Burden (Dollars) 703,814 0 0 70,801 0 633,013

Title Document Date Uploaded
Technical Release 2013-02 DOL TR 2013-02.pdf 01/25/2017
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.