Application for Free Clinics to Sponsor Individuals for Deemed PHS Employment with Liability Protections Under the FTCA

Applications for Deemed Public Health Service Employment with Liability Protections Under the FTCA for Health Centers, Deemed Health Center Volunteers, and Free Clinic Sponsored Individuals

Documents and Forms

Document Name Document Type
Form 4 Application for Free Clinics to Sponsor Individuals for Deemed PHS Employment with Liability Protections Under the FTCA Form and Instruction
4 Application for Free Clinics to Sponsor Individuals for FTCA Free Clinic Application Tool.pdf Form and Instruction
4 Application for Free Clinics to Sponsor Individuals for FTCA Free Clinic Application Tool.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Application for Free Clinics to Sponsor Individuals for Deemed PHS Employment with Liability Protections Under the FTCA	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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	4	Application for Free Clinics to Sponsor Individuals for Deemed PHS Employment with Liability Protections Under the FTCA	FTCA Free Clinic Application Tool.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 374	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,122	1,122
Annual IC Time Burden (Hours)	2,244	2,244
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.