Information Collection

Health Plan Information

IC 192647 under ICR 202310-0935-003 · OMB 0935-0165.

Documents and Forms

Document Name Document Type
Form Form #3 Health Plan Information Form and Instruction
Form #3 Health Plan Submission Attachment D -- Health Plan Information Form.pdf Form and Instruction
Form #3 Health Plan Submission Attachment D -- Health Plan Information Form.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Health Plan Information	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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
Form and Instruction	Form #3	Health Plan Submission	Attachment D -- Health Plan Information Form.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 75	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	300	300
Annual IC Time Burden (Hours)	150	150
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.