Information Collection

Att 5_Participant Eligiility Form

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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

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:

table that charts list of 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 %

table that charts list of burden
	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

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.