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⚠️ Notice: This information collection may be referencing outdated material.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 1 Free Clinics FTCA Program Application Form and Instruction
1 CY 2019 Free Clinic Program application CLEAN.docx CY 2019 Free Clinic Program application CLEAN.docx Form and Instruction

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 and Instruction	1	CY 2019 Free Clinic Program application CLEAN.docx	CY 2019 Free Clinic Program application CLEAN.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 228	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	684	684
Annual IC Time Burden (Hours)	1,368	1,368
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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