Information Collection

Indiana Survey

IC 264539 under ICR 202503-2900-010 · OMB 2900-0876.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0876 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Indiana WF 1.12.24 Indiana Survey	Form and Instruction
Form Indiana WF 1.12.24 Indiana WF 1.12.24 Indiana Survey	Form and Instruction
Indiana WF 1.12.24 Indiana WF 1.12.24 Indiana WF 1.12.24.docx	Form and Instruction
Indiana WF 1.12.24 Indiana WF 1.12.24 Indiana WF 1.12.24.docx	Form and Instruction
ICR Template_A11 Section 280 Clearance Indiana Survey 1.19.24.docx ICR Template_A11 Section 280 Clearance Indiana Survey 1.19.24	IC Document
ICR Template_A11 Section 280 Clearance Indiana Survey 1.19.24.docx ICR Template_A11 Section 280 Clearance Indiana Survey 1.19.24	IC Document

IC Title:

Indiana Survey

Agency IC Tracking Number:

2900-0876 Indiana Survey

IC Status: Unchanged

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	Indiana WF 1.12.24				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Veterans, Dependents of Veterans, and Veteran Beneficiaries Survey Records

FR Citation: 86 FR 6992

Number of Respondents: 2,500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	2,500	2,500
Annual IC Time Burden (Hours)	83	83
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
ICR Template_A11 Section 280 Clearance Indiana Survey 1.19.24		01/19/2024

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

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