Information Collection Request

Certificate of Coverage Request

ICR 202309-0960-007 · OMB 0960-0554 · Received in OIRA

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Justification for Non-Substantive Changes 0960-0554.docx Justification for No Material/Nonsubstantive Change Uploaded 2023-09-28 Missing upstream
Supporting Statement - 0554 (Final).docx Supporting Statement A Uploaded 2022-12-14 Repair queued

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
9477 Certificate of Coverage Request via Letter - Individuals (minus Denmark, Iceland, Netherlands, Norway, Slovenia, Sweden & Uruguay) Instruction Unchanged
222537 Certificate of Coverage Request via Internet - Employers (Poland) Instruction Modified
222536 Certificate of Coverage Request via Letter - Employers (Poland) Instruction Unchanged
222535 Certificate of Coverage Request via Internet - Individuals (Poland) Other-Internet Screens Modified
222534 Certificate of Coverage Request via Letter - Individuals (Poland) Instruction Unchanged
206903 Certificate of Coverage Request via Internet - Employers in Denmark, Iceland, Netherlands, Norway, Slovenia, Sweden & Uruguay) Other-Internet Application Modified
206902 Certificate of Coverage Request via Letter - Employers in Denmark, Iceland, Netherlands, Norway, Slovenia, Sweden & Uruguay) Instruction Unchanged
206901 Certificate of Coverage Request via Internet - Employers (minus Denmark, Netherlands, Norway, & Sweden and Urugay) Other-Internet Application Modified
206899 Certificate of Coverage Request via Letter - Employers (minus Denmark,Iceland, Netherlands, Norway, Poland, Solvenia, Sweden & Uruguay) Instruction Unchanged
206898 Certificate of Coverage Request via Internet - Individuals in Denmark, Iceland, Netherlands, Norway, Slovenia, Sweden & Uruguay Other-Internet Application Modified
206897 Certificate of Coverage Request via Letter - Individuals in Denmark, Netherlands, Norway, & Sweden, and Uruguay Instruction Modified
182116 Certificate of Coverage Request via Internet - Individuals (minus Denmark, Netherlands, Norway, & Sweden) Other-Internet Application Modified

ICR Details

Reginfo record details
table that charts list comparision
  Requested Previously Approved
02/28/2026 02/28/2026
32,722 32,722
21,975 21,975
0 0





table that charts list of burden
  Total Request Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 32,722 32,722 0 0 0 0
Annual Time Burden (Hours) 21,975 21,975 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No