Information Collection

Federal Tort Claims Act (FTCA) Program Deeming Sponsorship Applications for Free Clinics

IC 6548 under ICR 202010-0915-001 · OMB 0915-0293.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0293 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Federal Tort Claims Act (FTCA) Program Deeming Sponsorship Applications for Free Clinics	Form and Instruction
0293 Compare Free Clinic Deeming Application OLD v. NEW October 2020.docx	Other-Comapre/Mark-Up
1 0293 Free Clinic Program for CY 2021 Deeming - applicati 0293 Free Clinic Program for CY 2021 Deeming - application CLEAN FINAL October 2020.docx	Form and Instruction

IC Title:

Federal Tort Claims Act (FTCA) Program Deeming Sponsorship Applications for Free Clinics

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 and Instruction	1	0293 Free Clinic Program for CY 2021 Deeming - application CLEAN FINAL October 2020.docx	0293 Free Clinic Program for CY 2021 Deeming - application CLEAN FINAL October 2020.docx		Yes	Yes	Fillable Fileable
Other-Comapre/Mark-Up			0293 Compare Free Clinic Deeming Application OLD v. NEW October 2020.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 374

Number of Respondents for Small Entity: 374

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

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	1,122	438	684
Annual IC Time Burden (Hours)	2,244	876	1,368
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.