Information Collection

Application

IC 195986 under ICR 201101-0938-006 · OMB 0938-1119.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1119 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	Application	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 106	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	106	106
Annual IC Time Burden (Hours)	59,784	59,784
Annual IC Cost Burden (Dollars)	2,976,684	2,976,684

Documents for IC

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