Apllication Waiver/ Supplemental B Clinical Care

Application of Waiver of the 2 Year Foreign Residence Requirement of the Exchange Visitor Program

Documents and Forms

Document Name Document Type
Form 426 Apllication Waiver/ Supplemental B Clinical Care Form
426 Application 0990-0001waiver application.doc Form
426 Application 0990-0001waiver application.doc Form
426 Application 0990-0001_waiver-supplementary_A info.doc Form
426 Application 0990-0001_waiver-supplementary_A info.doc Form

Information Collection (IC) Details

IC Title:	Apllication Waiver/ Supplemental B Clinical Care	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 45 CFR 50.CFR

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	426	Application	0990-0001waiver application.doc		No	No	Paper Only
Form	426	Application	0990-0001_waiver-supplementary_A info.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 35	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	35	0	35
Annual IC Time Burden (Hours)	350	0	350
Annual IC Cost Burden (Dollars)	0	-43,750	43,750

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.