Information Collection

Att 5_Participant Eligiility Form

IC 231854 under ICR 201806-0920-009 · OMB 0920-1239.

Documents and Forms

Document Name Document Type
Form 0920- Att 5_Participant Eligiility Form Form
0920- Project NICE: Navigating Insurance Coverage Expansion - Att 5 Participant Eligibility Form 17AUZ FINAL 051818.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Att 5_Participant Eligiility Form	Agency IC Tracking Number:	0920-17AUZ

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	0920-	Project NICE: Navigating Insurance Coverage Expansion - Participant Eligibility Form	Att 5 Participant Eligibility Form 17AUZ FINAL 051818.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: 09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems	FR Citation: 57 FR 62812

Number of Respondents: 1,500	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	1,500	1,500
Annual IC Time Burden (Hours)	125	125
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.