Information Collection

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

IC 6548 under ICR 202105-0915-001 · OMB 0915-0293.

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
1 CY 2022 FREE CLINICS FTCA PROGRAM APPLICATION CLEAN.docx CY 2022 FREE CLINICS FTCA PROGRAM APPLICATION CLEAN.docx	Form
1 CY 2022 FREE CLINICS FTCA PROGRAM APPLICATION CLEAN.docx CY 2022 FREE CLINICS FTCA PROGRAM APPLICATION CLEAN.docx	Form
1 TC CY 2022 FREE CLINICS FTCA PROGRAM APPLICATION tracked ch CY 2022 FREE CLINICS FTCA PROGRAM APPLICATION tracked changes.docx	Form
1 TC CY 2022 FREE CLINICS FTCA PROGRAM APPLICATION tracked ch CY 2022 FREE CLINICS FTCA PROGRAM APPLICATION tracked changes.docx	Form
0293 Free Clinic Application Non Substantive Change Memo - CLEAN.docx 0293 Free Clinic Application Non Substantive Change Memo - CLEAN	IC Document
0293 Free Clinic Application Non Substantive Change Memo - CLEAN.docx 0293 Free Clinic Application Non Substantive Change Memo - CLEAN	IC Document

IC Title:

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	1	CY 2022 FREE CLINICS FTCA PROGRAM APPLICATION CLEAN.docx	CY 2022 FREE CLINICS FTCA PROGRAM APPLICATION CLEAN.docx		Yes	Yes	Fillable Fileable
Form	1 TC	CY 2022 FREE CLINICS FTCA PROGRAM APPLICATION tracked changes.docx	CY 2022 FREE CLINICS FTCA PROGRAM APPLICATION tracked changes.docx		Yes	Yes	Fillable Fileable

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	Previously Approved
Annual Number of Responses for this IC	1,122	1,122
Annual IC Time Burden (Hours)	2,244	2,244
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
0293 Free Clinic Application Non Substantive Change Memo - CLEAN	0293 Free Clinic Application Non Substantive Change Memo - CLEAN.docx	05/18/2021

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.