Free Clinics FTCA Program Application

Free Clinics FTCA Program Application

OMB: 0915-0293

IC ID: 6548

Information Collection (IC) Details

View Information Collection (IC)

Free Clinics FTCA Program Application
 
No Modified
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 1 CY 2019 Free Clinic Program application CLEAN.docx CY 2019 Free Clinic Program application CLEAN.docx Yes Yes Fillable Fileable

Health Health Care Services

 

228 0
   
Private Sector Not-for-profit institutions
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 684 0 0 0 0 684
Annual IC Time Burden (Hours) 1,368 0 0 0 0 1,368
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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