Information Collection

IPE, Long-Term

IC 272960 under ICR 202412-0906-005 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 6 IPE, Long-Term	Form and Instruction
6 IPE, Long-Term IPE-Long Term_30 day_final.pdf	Form and Instruction
6 IPE-Long-Term_finaldraftOMB 05.29.2025 IPE-Long-Term_finaldraftOMB 05.29.2025.pdf	Form and Instruction

IC Title:

IPE, Long-Term

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	6	IPE-Long-Term_finaldraftOMB 05.29.2025	IPE-Long-Term_finaldraftOMB 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: 4,403

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	4,403	4,403
Annual IC Time Burden (Hours)	308	308
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.