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

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

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Federal Tort Claims Act (FTCA) Program Deeming Sponsorship Applications for Free Clinics
 
No Modified
 
Required to Obtain or Retain Benefits
 

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

Health Health Care Services

 

374 374
   
Private Sector Not-for-profit institutions
 
   100 %

  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 1,122 0 0 0 0 1,122
Annual IC Time Burden (Hours) 2,244 0 0 0 0 2,244
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.