Information Collection

Immigrant Health Insurance Coverage

IC 238227 under ICR 201910-1405-001 · OMB 1405-0231.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DS-5541 Immigrant Health Insurance Coverage	Form
DS-5541 Immigrant Healthcare Questionnaire DS-5541.pdf	Form

IC Title:

Agency IC Tracking Number:

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	DS-5541	Immigrant Healthcare Questionnaire	DS-5541.pdf		No		Paper Only

Line of Business: International Affairs and Commerce

Subfunction: Foreign Affairs

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 450,500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	450,500	450,500
Annual IC Time Burden (Hours)	75,083	75,083
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.