FTCA Particularized Determination Application

Application for Federally Supported Health Centers Assistance Act (FSHCAA) / Federal Tort Claims Act (FTCA) Particularized Determination of Coverage

Documents and Forms

Document Name Document Type
Form 1 FTCA Particularized Determination Application Form and Instruction
1 FTCA Particularized Determination Application 0000-FTCA Particularized Determination-Application.docx Form and Instruction
1 FTCA Particularized Determination Application 0000-FTCA Particularized Determination-Application.docx Form and Instruction

Information Collection (IC) Details

IC Title:	FTCA Particularized Determination Application	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	FTCA Particularized Determination Application	0000-FTCA Particularized Determination-Application.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 12	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	12	12
Annual IC Time Burden (Hours)	24	24
Annual IC Cost Burden (Dollars)	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.