Information Collection

Participant Information Form

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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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
Instruction					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 %

table that charts list of burden
	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

table that charts IC Documents
Title	Document	Date Uploaded
Participant Information Form		06/30/2022
Event Record Information		06/30/2022

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

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