Information Collection

Web-based Update Mailer Attachment 3

IC 212546 under ICR 201711-0925-004 · OMB 0925-0639.

Documents and Forms

Document Name Document Type
Form 2 Web-based Update Mailer Attachment 3 Form and Instruction
2 Web-based Update Mailer Attachment 3 Web-based Update Mailer.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Web-based Update Mailer Attachment 3	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	Web-based Update Mailer	Attachment 3 Web-based Update Mailer.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 600	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	600	600
Annual IC Time Burden (Hours)	150	150
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.