Information Collection

Provider Enrollment Form

IC 13808 under ICR 200301-1215-005 · OMB 1215-0137.

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Documents and Forms

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Information Collection (IC) Details

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IC Title:	Provider Enrollment Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	OWCP01168				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 20,100	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	20,100	11,100	9,000
Annual IC Time Burden (Hours)	2,497	1,480	1,017
Annual IC Cost Burden (Dollars)	8,000	5,000	3,000

Documents for IC

Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.