Information Collection

Preventive Care SAQ

IC 264315 under ICR 202401-0935-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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 5a Preventive Care SAQ	Form and Instruction
5a Preventative Care SAQ Attachment 4 - PSAQ - fall 2024.pdf	Form and Instruction
5a Preventative Care SAQ Attachment 4 - PSAQ - fall 2024.pdf	Form and Instruction

IC Title:

Preventive Care SAQ

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
Form and Instruction	5a	Preventative Care SAQ	Attachment 4 - PSAQ - fall 2024.pdf		No		Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,688

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,844	2,844
Annual IC Time Burden (Hours)	332	332
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.