Information Collection

IPE, Long-Term

IC 272960 under ICR 202412-0906-005 · OMB unassigned.

Documents and Forms

Document Name Document Type
Form 6 IPE, Long-Term Form and Instruction
6 IPE, Long-Term IPE-Long Term_30 day_final.pdf Form and Instruction
6 IPE-Long-Term_finaldraftOMB 05.29.2025 IPE-Long-Term_finaldraftOMB 05.29.2025.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	IPE, Long-Term	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	6	IPE-Long-Term_finaldraftOMB 05.29.2025	IPE-Long-Term_finaldraftOMB 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: 4,403	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	4,403	4,403
Annual IC Time Burden (Hours)	308	308
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.