Information Collection

Participant Information Form

IC 254443 under ICR 202206-0915-001 · OMB 0915-0281.

Documents and Forms

Document Name Document Type
Participation Information Form_Final 5.4.2022.docx Instruction
Participation Information Form_Final 5.4.2022.docx Instruction
Participation Information Form_Final 5.4.2022.docx Participant Information Form IC Document
Participation Information Form_Final 5.4.2022.docx Participant Information Form IC Document
Event Record_Final 5.4.2022.docx Event Record Information IC Document
Event Record_Final 5.4.2022.docx Event Record Information IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Participant Information Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			Participation Information Form_Final 5.4.2022.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 164,835	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	164,835	164,835
Annual IC Time Burden (Hours)	27,473	27,473
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Participant Information Form	Participation Information Form_Final 5.4.2022.docx	06/30/2022
Event Record Information	Event Record_Final 5.4.2022.docx	06/30/2022

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