Request for Employment Information

ICR 200001-0938-001

OMB: 0938-0787

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
8552 Migrated
ICR Details
0938-0787 200001-0938-001
Historical Active
HHS/CMS
Request for Employment Information
Existing collection in use without an OMB Control Number   No
Regular
Approved without change 04/04/2000
Retrieve Notice of Action (NOA) 01/06/2000
Approved for use through 4/2001 under the condition that the next submission for OMB review includes an evaluation of burden reductions that may be possible through data matches with other Federal agencies.
  Inventory as of this Action Requested Previously Approved
04/30/2001 04/30/2001
5,000 0 0
750 0 0
0 0 0

This information is needed to determine whether a beneficiary can enroll in Part B and/or qualify for premium reduction.

None
None


No

1
IC Title Form No. Form Name
Request for Employment Information HCFA-R-297

  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 5,000 0 0 5,000 0 0
Annual Time Burden (Hours) 750 0 0 750 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
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.
01/06/2000


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