Information Collection

Eligibility and Registration Form

IC 232081 under ICR 201807-0935-001 · OMB 0935-0242.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0242 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Eligibility and Registration Form	Form and Instruction
1 Eligibility and Registration Form Attachment A - Eligibility and Registration Form 11.6.17.docx	Form and Instruction

IC Title:

Eligibility and Registration Form

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	Eligibility and Registration Form	Attachment A - Eligibility and Registration Form 11.6.17.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

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	100	100
Annual IC Time Burden (Hours)	8	8
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.