Information Collection

Attachment 19 – HC Adult SAQ – Male

IC 230227 under ICR 202209-0935-003 · OMB 0935-0118.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0118 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Attachment 19 Attachment 19 – HC Adult SAQ – Male	Form and Instruction
Attachment 19 Attachment 19 – HC Adult SAQ – Male Attachment 19 HC Adult SAQ Male.docx	Form and Instruction
Attachment 19 Attachment 19 – HC Adult SAQ – Male Attachment 19 HC Adult SAQ Male.docx	Form and Instruction
Attachment 18 Attachment 18 HC Adult SAQ Attachment 18 HC Adult SAQ.pdf	Form and Instruction
Attachment 18 Attachment 18 HC Adult SAQ Attachment 18 HC Adult SAQ.pdf	Form and Instruction

IC Title:

Attachment 19 â HC Adult SAQ â Male

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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
Form and Instruction	Attachment 19	Attachment 19 â HC Adult SAQ â Male	Attachment 19 HC Adult SAQ Male.docx		No		Paper Only
Form and Instruction	Attachment 18	Attachment 18 HC Adult SAQ	Attachment 18 HC Adult SAQ.pdf		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 11,985

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	11,985	11,985
Annual IC Time Burden (Hours)	1,398	1,398
Annual IC Cost Burden (Dollars)	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.