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OMB Control No: 3206-0141	ICR Reference No: 199011-3206-001
Status: Historical Active	Previous ICR Reference No: 199008-3206-007
Agency/Subagency: OPM	Agency Tracking No:
Title: OPM 2809-HEALTH BENEFITS REGISTRATION FORM, OPM 2809 EZ-1, 2 HEALTH BENEFITS ENROLLMENT CHANGE FORM, DPRS 2809, REQUEST TO CHANGE FEHB ENROLLMENT OR TO RECEIVE PLAN BROCHURES FOR..
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/05/1990
	Date Received in OIRA: 11/23/1990
Terms of Clearance: 1. This action by OMB adds to the existing approval under OMB control number 3206-0141, the DPRS Form 2809 and its instructions. 2. This action changes the expiration date for all forms approved under this control number to June 1991. 3. This change in the expiration date is made because of the large amount of public comment being received at OMB during the current open season regarding the confusing nature of the instructions. Specifically, individuals receiving open season material have complained about the burden associated with understanding the form due to a lack of clarity regarding what to do if no change in health benefit plan is desired. Representative letters received by OMB on this subject are being forwarded to Ron Trueworthy of OPM under seperate cover. 4. In its next request for approval of these forms, prior to the next open season, OPM should demonstrate responsiveness to the complaints described above by making modifications to the draft open season material submitted for OPM approval.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/1991	06/30/1991	06/30/1992
Responses	295,500	0	285,500
Time Burden (Hours)	147,750	0	142,750
Cost Burden (Dollars)	0	0	0

Abstract: OPM 2809 IS USED TO ELECT, CANCEL OR CHANGE HEALTH BENEFITS DURING PERIODS OTHER THAN OPEN SEASON. OPM 2809 EZ-1, 2 ARE USED BY ANNUITANT AND SURVIVOR ANNUITANTS WHO CHOOSE TO CHANGE HEALTH BENEFITS DURING OPEN SEASON. DPRS 2809 IS USED BY FORMER SPOUSE AND TEMPORARY CONTINUATION OF COVERAGE ENROLLEES, DURING OPEN SEASON, TO CHANGE FEHB

Authorizing Statute(s): None

Citations for New Statutory Requirements: None

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:

Federal Register Notices & Comments
Did the Agency receive public comments on this ICR? No

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Agency Discretion
Annual Number of Responses	295,500	285,500	10,000
Annual Time Burden (Hours)	147,750	142,750	5,000
Annual Cost Burden (Dollars)	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

View ICR - OIRA Conclusion