Information Collection

Participant Eligibility Disposition

IC 220455 under ICR 201603-0920-004 · OMB 0920-1133.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1133 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Participant Eligibility Disposition	Form
Participant Eligibility Disposition Att 11a&b_ParticiEligibilityDispo form.docx	Form

IC Title:

Participant Eligibility Disposition

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Participant Eligibility Disposition	Att 11a&b_ParticiEligibilityDispo form.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	36	36
Annual IC Time Burden (Hours)	36	36
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.