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Federal forms, ICRs, and supporting documents

Information Collection Request

OPM 2809: HEALTH BENEFITS REGISTRATION FORM OPM 2809, EZ-1, 2: HEALTH BENEFITS ENROLLMENT CHANGE FORM

ICR 199008-3206-007 · OMB 3206-0141 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC IDCollectionTypeStatusForm
156940 OPM 2809: HEALTH BENEFITS REGISTRATION FORM OPM 2809, EZ-1, 2: HEALTH BENEFITS ENROLLMENT CHANGE FORM Form Migrated
ICR Details
3206-0141 199008-3206-007
Historical Active 198903-3206-011
OPM
OPM 2809: HEALTH BENEFITS REGISTRATION FORM OPM 2809, EZ-1, 2: HEALTH BENEFITS ENROLLMENT CHANGE FORM
Extension without change of a currently approved collection   No
Regular
Approved without change 10/05/1990
Retrieve Notice of Action (NOA) 08/14/1990
This limited approval is given in light of OPM's commitment to restructure the current FEHBP. It is anticipated that any changed FEHBP will require substantially changed forms requiring OMB approval under the Paperwork Reduction Act. OPM may modify dates in form instruction to make appropriate references to each open season year.
  Inventory as of this Action Requested Previously Approved
06/30/1992 06/30/1992 08/31/1990
285,500 0 285,500
142,750 0 142,750
0 0 0
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.
None
None
No
1
IC Title Form No. Form Name
OPM 2809: HEALTH BENEFITS REGISTRATION FORM OPM 2809, EZ-1, 2: HEALTH BENEFITS ENROLLMENT CHANGE FORM OPM 2809, 2809, EZ-1, 2
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 285,500 285,500 0 0 0 0
Annual Time Burden (Hours) 142,750 142,750 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected
  No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
08/14/1990