Information Collection

Federal Government Initial Request

IC 228618 under ICR 202008-0925-001 · OMB 0925-0703.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0703 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Initial Request screenshot Federal Government Initial Request	Form
1 Initial Request screenshot A2 - Initial Request (2).docx	Form

IC Title:

Federal Government Initial Request

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	1				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 60

Number of Respondents for Small Entity: 0

Affected Public: Federal Government

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	60	60
Annual IC Time Burden (Hours)	30	30
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.

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