Information Collection

Checklist for Adding a New Target Population

IC 207843 under ICR 202505-0915-002 · OMB 0915-0285.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0285 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 4 Checklist for Adding a New Target Population	Form and Instruction
Form 4 Checklist for Adding a New Target Population - Clean.docx Checklist for Adding a New Target Population	Form and Instruction
Form 4E Checklist for Adding a New Target Population edits.docx Checklist for Adding a New Target Population	Form and Instruction
4 Checklist for Adding a New Target Population - Clean.doc Checklist for Adding a New Target Population - Clean.docx	Form and Instruction
4 Checklist for Adding a New Target Population - Clean.doc Checklist for Adding a New Target Population - Clean.docx	Form and Instruction
4E Checklist for Adding a New Target Population edits.docx Checklist for Adding a New Target Population edits.docx	Form and Instruction
4E Checklist for Adding a New Target Population edits.docx Checklist for Adding a New Target Population edits.docx	Form and Instruction

IC Title:

Checklist for Adding a New Target Population

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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	4				Yes	Yes	Fillable Fileable
Form and Instruction	4E				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	200	200
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.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].