Certificates for Health Care Benefits

ICR 200207-1115-001

OMB: 1115-0226

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
12211
Migrated
ICR Details
1115-0226 200207-1115-001
Historical Active 199905-1115-007
DOJ/INS
Certificates for Health Care Benefits
Extension without change of a currently approved collection   No
Regular
Approved without change 09/23/2002
Retrieve Notice of Action (NOA) 07/29/2002
  Inventory as of this Action Requested Previously Approved
09/30/2005 09/30/2005 09/30/2002
21,000 0 14,000
37,240 0 25,620
4,550,000 0 2,100,000

The data collected and displayed on all health care worker certificates will be used by a benefit granting agency to determine whether or not a health care worker coming to work in the United states is inadmissible under sction 212(a)(5)(C) of the Act, to establish that the certificate relates to the health care workers who present themselves for admission or adjustment of status, and to provide the Service with a means of contacting the issuing organization to verify the certificate's validity quickly.

None
None


No

1
IC Title Form No. Form Name
Certificates for Health Care Benefits

  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 21,000 14,000 0 0 7,000 0
Annual Time Burden (Hours) 37,240 25,620 0 0 11,620 0
Annual Cost Burden (Dollars) 4,550,000 2,100,000 0 2,450,000 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.
07/29/2002


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