Free Clinics FTCA Program Application

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0293 can be found here:

Documents and Forms

Document Name Document Type
Form Free Clinics 1 Free Clinics FTCA Program Application Form
pal201109 - 2012 Application PAL.pdf Instruction
Free Clinics 1 Free Clinics Application 2012 deemingapplication.xls Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Free Clinics FTCA Program Application	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	Free Clinics 1	Free Clinics Application	2012 deemingapplication.xls		Yes	Yes	Fillable Fileable
Instruction			pal201109 - 2012 Application PAL.pdf		Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 200	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	200	50	150
Annual IC Time Burden (Hours)	2,800	400	2,400
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.