Information Collection

Application For School Of Medicine-special Requirements And Assurances Under Health Professions Capitation Grant Program

IC 112079 under ICR 197806-0935-001 · OMB 0935-0014.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0014 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	APPLICATION FOR SCHOOL OF MEDICINE-SPECIAL REQUIREMENTS AND ASSURANCES UNDER HEALTH PROFESSIONS CAPITATION GRANT PROGRAM	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

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

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,620	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	3,620	-640	4,260
Annual IC Time Burden (Hours)	2,810	-1,990	4,800
Annual IC Cost Burden (Dollars)	0	0	0

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Title	Document	Date Uploaded

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