Information Collection

Application For Schools Of Medicine-special Requirements And Assurances Under Health Professions Capitation

IC 112080 under ICR 198006-0935-001 · OMB 0935-0014.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

APPLICATION FOR SCHOOLS OF MEDICINE-SPECIAL REQUIREMENTS AND ASSURANCES UNDER HEALTH PROFESSIONS CAPITATION

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:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?
Form	HRA198	No	No
Form	HRA1981A	No	No
Form	HRA1981B	No	No

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 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	3,620	3,620
Annual IC Time Burden (Hours)	2,810	2,810
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded

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