INDIVIDUALIZED SERVICE PLAN (SHORT FORM, EXTENDED FORM 1 AND 2)

ICR 197609-0938-002

OMB: 0938-0057

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
0938-0057 197609-0938-002
Historical Active
HHS/CMS
INDIVIDUALIZED SERVICE PLAN (SHORT FORM, EXTENDED FORM 1 AND 2)
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 10/13/1976
Retrieve Notice of Action (NOA) 09/29/1976
  Inventory as of this Action Requested Previously Approved
05/31/1981 05/31/1981
60 0 0
11 0 0
0 0 0



None
None


No

1
IC Title Form No. Form Name
INDIVIDUALIZED SERVICE PLAN (SHORT FORM, EXTENDED FORM 1 AND 2) SSA-3407, 34, 3407B

  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 60 0 0 0 60 0
Annual Time Burden (Hours) 11 0 0 0 11 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.
09/29/1976


© 2024 OMB.report | Privacy Policy