Information Collection

AmeriCorps NCCC Medical Form

IC 223732 under ICR 201609-3045-002 · OMB 3045-0183.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 AmeriCorps NCCC Medical Form	Form and Instruction
1 AmeriCorps NCCC Medical Form NCCC MMHIF PDF 12.2016.pdf www.nationalservice.gov	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	AmeriCorps NCCC Medical Form	NCCC MMHIF PDF 12.2016.pdf	www.nationalservice.gov	Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Community and Regional Development

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 8,500

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	8,500	8,500
Annual IC Time Burden (Hours)	2,125	2,125
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.