MIGRANT HOSPITALIZATION DEMONSTRATION PROGRAM REFERRAL FORM

ICR 197608-0915-001

OMB: 0915-0001

Federal Form Document

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Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
0915-0001 197608-0915-001
Historical Active 197501-0915-001
HHS/HSA
MIGRANT HOSPITALIZATION DEMONSTRATION PROGRAM REFERRAL FORM
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 09/03/1976
Retrieve Notice of Action (NOA) 08/24/1976
  Inventory as of this Action Requested Previously Approved
09/30/1977 09/30/1977
3,600 0 0
900 0 0
0 0 0



None
None


No

1
IC Title Form No. Form Name
MIGRANT HOSPITALIZATION DEMONSTRATION PROGRAM REFERRAL FORM HSA-T1

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 3,600 0 0 0 3,600 0
Annual Time Burden (Hours) 900 0 0 0 900 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
08/24/1976


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