Information Collection

Incentives Pilot Project Sign Up form – Only for Texas Registrants

IC 269810 under ICR 202408-0923-001 · OMB 0923-0041.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0041 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Incentives Pilot Project Sign Up form – Only for Texas Registrants	Form and Instruction
Incentive Project Sign Up Form Incentives Pilot Project Sign Up form – Only for Texas Registrants	Form and Instruction
Incentive Project Sign Up Form Appendix U2- Incentive Project Sign Up Form -New.docx	Form and Instruction
Incentive Project Sign Up Form Appendix U2- Incentive Project Sign Up Form -New.docx	Form and Instruction

IC Title:

Incentives Pilot Project Sign Up form â Only for Texas Registrants

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	n/a				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	5	5
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.

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