Information Collection

471 HealthIT+qnaire+for+dataload+final;472CQs for OMB started 7-8-2011; 473 SSA iClaim v2

IC 198660 under ICR 201101-1090-002 · OMB 1090-0008.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1090-0008 can be found here:

Documents and Forms

Document Name Document Type
Form 471 HealthIT+qnair 471 HealthIT+qnaire+for+dataload+final;472CQs for OMB started 7-8-2011; 473 SSA iClaim v2 Form
471 HealthIT+qnair 471 HealthIT+qnaire+for+dataload+final 2011 471 Copy of HealthIT+qnaire+for+dataload+final.xlsx Form
472 CQs for OMB st 472 CQs for OMB started 7-8-2011 2011 472 CQs for OMB started 7-8-2011.xlsx Form
473 SSA iClaim v2 473 SSA iClaim v2 2011 473 SSA iClaim v2.xlsx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	471 HealthIT+qnaire+for+dataload+final;472CQs for OMB started 7-8-2011; 473 SSA iClaim v2	Agency IC Tracking Number:	471-473

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	471 HealthIT+qnaire+for+dataload+final	471 HealthIT+qnaire+for+dataload+final	2011 471 Copy of HealthIT+qnaire+for+dataload+final.xlsx	Yes	Yes	Fillable Fileable
Form	472 CQs for OMB started 7-8-2011	472 CQs for OMB started 7-8-2011	2011 472 CQs for OMB started 7-8-2011.xlsx	Yes	Yes	Fillable Fileable
Form	473 SSA iClaim v2	473 SSA iClaim v2	2011 473 SSA iClaim v2.xlsx	Yes	Yes	Fillable Fileable

Line of Business: General Government

Subfunction: Central Records & Statistical Mgt

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 15,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	15,000	15,000
Annual IC Time Burden (Hours)	625	625
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.