OMB
.report
Search
Immigrant Health Insurance Coverage
Immigrant Health Insurance Coverage
OMB: 1405-0231
IC ID: 238227
OMB.report
STATE/AFA
OMB 1405-0231
ICR 201910-1405-001
IC 238227
( )
Documents and Forms
Document Name
Document Type
Form DS-5541
Immigrant Health Insurance Coverage
Form
DS-5541 Immigrant Healthcare Questionnaire
DS-5541.pdf
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Immigrant Health Insurance Coverage
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:
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
Federal Enterprise Architecture Business Reference Module
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 %
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
450,500
0
450,500
0
0
0
Annual IC Time Burden (Hours)
75,083
0
75,083
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
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.
