Information Collection

Participant Information Form (PIF)

IC 221598 under ICR 201905-0915-001 · OMB 0915-0281.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0281 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form D Participant Information Form (PIF)	Form
D Participation Information Form 218 D_Participation Information Form 2018_Final.pdf	Form

IC Title:

Participant Information Form (PIF)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	D	Participation Information Form 218	D_Participation Information Form 2018_Final.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 61,288

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	61,288	-53,135	114,423
Annual IC Time Burden (Hours)	3,064	-4,946	8,010
Annual IC Cost Burden (Dollars)	0	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.