Information Collection

Individual Participant Record

IC 272954 under ICR 202412-0906-005 · OMB unassigned.

Documents and Forms

Document Name Document Type
Form 1 Individual Participant Record Form and Instruction
1 Individual Participant Record IND-PAR_30 day_final.pdf Form and Instruction
1 IND-PAR_draftfinalOMB 05.29.2025 IND-PAR_draftfinalOMB 05.29.2025.pdf Form and Instruction
IND-PAR_30 day_tracked_FINAL.docx IND-PAR Tracked Changes IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Individual Participant Record	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	IND-PAR_draftfinalOMB 05.29.2025	IND-PAR_draftfinalOMB 05.29.2025.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 59,576	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 80 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	59,576	59,576
Annual IC Time Burden (Hours)	16,086	16,086
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
IND-PAR Tracked Changes	IND-PAR_30 day_tracked_FINAL.docx	01/10/2025

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.