Information Collection

AmeriCorps NCCC Medical Form

IC 223732 under ICR 201609-3045-002 · OMB 3045-0183.

Documents and Forms

Document Name Document Type
Form 1 AmeriCorps NCCC Medical Form Form and Instruction
1 AmeriCorps NCCC Medical Form NCCC MMHIF PDF 12.2016.pdf www.nationalservice.gov Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	AmeriCorps NCCC Medical Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

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	AmeriCorps NCCC Medical Form	NCCC MMHIF PDF 12.2016.pdf	www.nationalservice.gov	Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Community and Regional Development

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 8,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	8,500	8,500
Annual IC Time Burden (Hours)	2,125	2,125
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.