View Information Collection Request (ICR) Package

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View ICR - OIRA Conclusion

OMB Control No: 0915-0293	ICR Reference No: 200409-0915-002
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/HSA	Agency Tracking No:
Title: Free Clinics FTCA Program Application
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR: No
Type of Review Request: Emergency	Approval Requested By: 09/24/2004
OIRA Conclusion Action: Approved with change	Conclusion Date: 09/22/2004
	Date Received in OIRA: 09/13/2004
Terms of Clearance: Approved consistent with HRSA memo forwarded to OMB 09/20/04. HRSA will require information regarding the medical malpractice history of all individuals added through the supplemental form as well as in the annual application submitted by each Free Clinic. As soon as possible but no later than 4 months from the date of approval of this emergency request HRSA must publish a 60 day notice in the federal register and initiate the standard PRA clearance process.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2005	06/30/2005
Responses	600	0	0
Time Burden (Hours)	3,000	0	0
Cost Burden (Dollars)	0	0	0

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