Information Collection

CLC Form and Instruction for Part B

IC 242544 under ICR 202302-0915-001 · OMB 0915-0318.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0318 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form B-5 CLC Form and Instruction for Part B	Form and Instruction
B-5 CLC_Part B_With Synchronization Warning.png CLC_Part B_With Synchronization Warning.png	Form and Instruction
B-5 CLC_Part B_With Synchronization Warning.png CLC_Part B_With Synchronization Warning.png	Form and Instruction

IC Title:

CLC Form and Instruction for Part B

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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 and Instruction	B-5	CLC_Part B_With Synchronization Warning.png	CLC_Part B_With Synchronization Warning.png		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 54

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-54	54
Annual IC Time Burden (Hours)	-108	108
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.