Information Collection

Doi

IC 35967 under ICR 200704-4040-002 · OMB 4040-0005.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 4040-0005 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 424 DOI	Form
424 Individual SF424_Individual-V1 0_SSNMockup2.pdf	Form

IC Title:

DOI

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 5 CFR 1320.5 (d)(2)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	424	Individual	SF424_Individual-V1 0_SSNMockup2.pdf		No	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 110

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	220	-6,729	6,949
Annual IC Time Burden (Hours)	92	-2,771	2,863
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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