Information Collection

Non-Participant Components Informant Contact (Pre-exam and Annual Follow-up)

IC 221016 under ICR 201604-0925-002 · OMB 0925-0216.

Documents and Forms

Document Name Document Type
Form 2 Non-Participant Components Informant Contact (Pre-exam and Annual Follow-up) Form and Instruction
2 Attachment 3 Medical History Attach 3 Medical History.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Non-Participant Components Informant Contact (Pre-exam and Annual Follow-up)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	2	Attachment 3 Medical History	Attach 3 Medical History.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 150	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	150	150
Annual IC Time Burden (Hours)	25	25
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.