View Information Collection Request (ICR) Package

Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.

View ICR - OIRA Conclusion

OMB Control No: 3206-0141	ICR Reference No: 202304-3206-001
Status: Historical Active	Previous ICR Reference No: 202003-3206-002
Agency/Subagency: OPM	Agency Tracking No: OPM 2809, Health Benefits Election Form
Title: OPM 2809, Health Benefits Election Form
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 02/22/2024
	Date Received in OIRA: 04/21/2023
Terms of Clearance: This collection is approved based on the revised materials provided by the Agency.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2027	36 Months From Approved	02/29/2024
Responses	30,000	0	30,000
Time Burden (Hours)	11,667	0	11,667
Cost Burden (Dollars)	313,500	0	313,500

Annual Cost to Federal Government: $87,650

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. Yes

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

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

Agency Contact: Demetrius Jones 202 606-5203 demetrius.jones@opm.gov

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