Attachment 5. Annual Aggregate Data on Medically Ineligible Clients Form

Colorectal Cancer Screening Demonstration Program

OMB: 0920-0745

IC ID: 179137

Information Collection (IC) Details

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Attachment 5. Annual Aggregate Data on Medically Ineligible Clients Form
 
No New
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction None Annual Aggregate Data on Medically Ineligible Clients Form 0920-05CJ ATTACHMENT 5 Aggregate Medically Ineligible Form.doc Yes Yes Fillable Printable

Health Public Health Monitoring

 

5 0
   
State, Local, and Tribal Governments
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 5 0 5 0 0 0
Annual IC Time Burden (Hours) 5 0 5 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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