Att 5_Participant Eligiility Form

Project NICE: Navigating Insurance Coverage Expansion

OMB: 0920-1239

IC ID: 231854

Information Collection (IC) Details

View Information Collection (IC)

Att 5_Participant Eligiility Form 0920-17AUZ
 
No New
 
Required to Obtain or Retain Benefits
 

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

Health Illness Prevention

09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems  57 FR 62812

1,500 0
   
Individuals or Households
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 1,500 0 1,500 0 0 0
Annual IC Time Burden (Hours) 125 0 125 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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