Information Collection

Individual Participant Record

IC 272954 under ICR 202412-0906-005 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Individual Participant Record	Form and Instruction
1 Individual Participant Record IND-PAR_30 day_final.pdf	Form and Instruction
1 IND-PAR_draftfinalOMB 05.29.2025 IND-PAR_draftfinalOMB 05.29.2025.pdf	Form and Instruction
IND-PAR_30 day_tracked_FINAL.docx IND-PAR Tracked Changes	IC Document

IC Title:

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:

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	1	IND-PAR_draftfinalOMB 05.29.2025	IND-PAR_draftfinalOMB 05.29.2025.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 59,576

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 80 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	59,576	59,576
Annual IC Time Burden (Hours)	16,086	16,086
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
IND-PAR Tracked Changes	IND-PAR_30 day_tracked_FINAL.docx	01/10/2025

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.