Information Collection

Immigrant Health Insurance Coverage

IC 238227 under ICR 201910-1405-001 · OMB 1405-0231.

Documents and Forms

Document Name Document Type
Form DS-5541 Immigrant Health Insurance Coverage Form
DS-5541 Immigrant Healthcare Questionnaire DS-5541.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Immigrant Health Insurance Coverage	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	DS-5541	Immigrant Healthcare Questionnaire	DS-5541.pdf		No		Paper Only

Line of Business: International Affairs and Commerce

Subfunction: Foreign Affairs

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 450,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	450,500	450,500
Annual IC Time Burden (Hours)	75,083	75,083
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.