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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

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.