OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Health Benefits Election Form

ICR 201408-3206-004 · OMB 3206-0160 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form SF 2809 Health Benefits Election Form Form and Instruction Modified Repair queued
30-Day FRN.pdf Supplementary Document Uploaded 2014-08-28 Available
60-Day FRN.pdf Supplementary Document Uploaded 2014-08-27 Available
SF 2809 November 2014 Markup.pdf Supplementary Document Uploaded 2014-08-27 Available
SF2809_August2011 Markup.pdf Supplementary Document Uploaded 2014-08-27 Available
SF 2809 SS.doc Supporting Statement A Uploaded 2014-08-27 Available
IC Document Collections
IC IDCollectionTypeStatusForm
33632 Health Benefits Election Form Form and Instruction Modified
ICR Details
3206-0160 201408-3206-004
Historical Active 201106-3206-005
OPM
Health Benefits Election Form
Revision of a currently approved collection   No
Regular
Approved without change 10/27/2014
Retrieve Notice of Action (NOA) 08/28/2014
  Inventory as of this Action Requested Previously Approved
10/31/2017 36 Months From Approved 10/31/2014
18,000 0 18,000
9,000 0 9,000
0 0 0
SF 2809, Health Benefits Election Form, is used by Federal employees, annuitants other than those under the Civil Service Retirement System (CSRS) and the Federal Employees Retirement System (FERS) including individuals receiving benefits from the Office of Workers' Compensation Programs, former spouses eligible for benefits under the Spouse Equity Act of 1984, and separated employees and former dependents eligible to enroll under the Temporary Continuation of Coverage provisions of the FEHB law (5 U.S.C. 8905a). A different form (OPM 2809) is used by CSRS and FERS annuitants whose health benefit enrollments are administered by OPM's Retirement Operations. The form was revised to bring the web sites up to date, and to make additional minor editorial changes. The employee's email address and preferred telephone number were moved from Part H to Part A. On page 2 of the form, fields were added to collect the enrollee's name and date of birth. The Privacy Act Statement and Public Burden Statement were combined and updated to be consistent with current legislation.
US Code: 5 USC 8905a Name of Law: Continued Coverage
   PL: Pub.L. 98 - 615 CSRS Name of Law: Spouse Equity Act of 1984
   US Code: 5 USC 89 Name of Law: Health Insurance
  
None
Not associated with rulemaking
  79 FR 23020 04/25/2014
79 FR 51378 08/28/2014
No
1
IC Title Form No. Form Name
Health Benefits Election Form SF 2809 Health Benefits Election Form
  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 18,000 18,000 0 0 0 0
Annual Time Burden (Hours) 9,000 9,000 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$16,000
No
No
Yes
No
No
Uncollected
Steve Pierce 202 606-2560 [email protected]
  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.
08/28/2014