Information Collection

Application for Free Clinics to Sponsor Individuals for Deemed PHS Employment with Liability Protections Under the FTCA

IC 266935 under ICR 202512-0906-001 · OMB 0906-0090.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 4 Application for Free Clinics to Sponsor Individuals for Deemed PHS Employment with Liability Protections Under the FTCA	Form and Instruction
Form 4 Application for Free Clinics to Sponsor Individuals for Deemed PHS Employment with Liability Protections Under the FTCA Application for Free Clinics to Sponsor Individuals for Deemed PHS Employment with Liability Protections Under the FTCA	Form and Instruction
4 Application for Free Clinics to Sponsor Individuals for Clean_FTCA Application for Free Clinics to Sponsor Individuals for Deemed PHS Employment 0906-0090.docx	Form and Instruction
4 Application for Free Clinics to Sponsor Individuals for Clean_FTCA Application for Free Clinics to Sponsor Individuals for Deemed PHS Employment 0906-0090.docx	Form and Instruction
Redline_FTCA Application for Free Clinics to Sponsor Individuals for Deemed PHS Employment 0906-0090.pdf Redline_FTCA Application for Free Clinics to Sponsor Individuals for Deemed PHS Employment 0906-0090	IC Document
Redline_FTCA Application for Free Clinics to Sponsor Individuals for Deemed PHS Employment 0906-0090.pdf Redline_FTCA Application for Free Clinics to Sponsor Individuals for Deemed PHS Employment 0906-0090	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 374

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	1,122	1,122
Annual IC Time Burden (Hours)	2,244	2,244
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Redline_FTCA Application for Free Clinics to Sponsor Individuals for Deemed PHS Employment 0906-0090		12/10/2025

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

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