OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

SF 2809 Federal Employees Health Benefits Program Election Form; OPM 2809 Health Benefits Election Form

ICR 202504-3206-001 · OMB 3206-0160 · Active

Forms and Documents
DocumentTypeStatusAvailability
Form OPM 2809 Health Benefits Election Form Form and Instruction Unchanged Available
Form SF 2809 Federal Employees Health Benefits Program Election Form Form and Instruction Unchanged Available
Form SF 2809 Health Benefits Election Form Form and Instruction Unchanged Repair queued
Non-Substantive_Change_Request_HB_Election_Forms_2025.docx Justification for No Material/Nonsubstantive Change Uploaded 2025-04-02 Repair queued
Non-Substantive_Change_Request_HB_Election_Forms_2025.docx Justification for No Material/Nonsubstantive Change Uploaded 2025-04-02 Missing upstream
Health Benefit Election Forms (Supporting Statement Part A)_final.docx Supporting Statement A Uploaded 2024-11-12 Available
Health Benefit Election Forms (Supporting Statement Part A)_final.docx Supporting Statement A Uploaded 2024-11-12 Missing upstream
E8-5659.pdf Supplementary Document Uploaded 2022-04-28 Repair queued
E8-5659.pdf Supplementary Document Uploaded 2022-04-28 Repair queued
Citations for SF 2809.pdf Supplementary Document Uploaded 2022-04-28 Available
Citations for SF 2809.pdf Supplementary Document Uploaded 2022-04-28 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
33632 Health Benefits Election Form Form and Instruction UnchangedHealth Benefits Election Form
33632 Health Benefits Election Form Form and Instruction UnchangedFederal Employees Health Benefits Program Election Form
33632 Health Benefits Election Form Form and Instruction Unchanged
ICR Details
3206-0160 202504-3206-001
Active 202410-3206-002
OPM
SF 2809 Federal Employees Health Benefits Program Election Form; OPM 2809 Health Benefits Election Form
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 04/03/2025
Retrieve Notice of Action (NOA) 04/02/2025
  Inventory as of this Action Requested Previously Approved
11/30/2027 11/30/2027 11/30/2027
48,000 0 48,000
20,667 0 20,667
477,514 0 477,514
The SF 2809 is used to enroll, elect not to enroll, change, suspend or cancel your health insurance coverage in the Federal Employees Health Benefits (FEHB) Program which includes FEHB and Postal Service Health Benefits (PSHB) plans. A different form (OPM 2809) is used by annuitants retired under the Civil Service Retirement System (CSRS) or Federal Employees' Retirement System (FERS), electing or changing either there FEHB or Postal Service Health Benefit (PSHB) coverage under the FEHB Program as well as the following: children and former spouses who are eligible for temporary continuation of coverage; former spouses; survivor annuitants under CSRS or FERS; an OPM appointed representative payee or court appointed guardian of the eligible member.
US Code: 5 USC 8905a Name of Law: Continued Coverage
   US Code: 5 USC 89 Name of Law: Health Insurance
   PL: Pub.L. 98 - 615 CSRS Name of Law: Spouse Equity Act of 1984
  
None
3206-AO43 Final or interim final rulemaking 89 FR 37061 05/06/2024
  89 FR 37269 05/06/2024
89 FR 77899 09/24/2024
Yes
1
IC Title Form No. Form Name
Health Benefits Election Form OPM 2809, SF 2809 Federal Employees Health Benefits Program Election Form ,   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 48,000 48,000 0 0 0 0
Annual Time Burden (Hours) 20,667 20,667 0 0 0 0
Annual Cost Burden (Dollars) 477,514 477,514 0 0 0 0
No
No
The Postal Service Health Benefit Act requires changes in burden due to Congressional act. We are also including another collection in this ICR.
$107,944
No
    Yes
    Yes
Yes
No
No
Yes
Alexys Stanley 202 606-1183 [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.
04/02/2025