Request for Employment Information

ICR 200106-0938-008

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
8553 Migrated
ICR Details
0938-0787 200106-0938-008
Historical Active 200001-0938-001
HHS/CMS
Request for Employment Information
Extension without change of a currently approved collection   No
Regular
Approved without change 08/24/2001
Retrieve Notice of Action (NOA) 06/15/2001
  Inventory as of this Action Requested Previously Approved
09/30/2004 09/30/2004 08/31/2001
5,000 0 5,000
750 0 750
0 0 0

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

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 5,000 0 0 0 0
Annual Time Burden (Hours) 750 750 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.
06/15/2001


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