Information Collection

Health Systems Agency Application For Designation, Grant Applications And Related Report Forms

IC 165968 under ICR 198106-0935-003 · OMB 0935-0017.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

HEALTH SYSTEMS AGENCY APPLICATION FOR DESIGNATION, GRANT APPLICATIONS AND RELATED REPORT FORMS

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Migrated

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?
Form	217-1	No	No
Form	217-2	No	No
Form	217-3	No	No

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 204

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	Previously Approved
Annual Number of Responses for this IC	204	204
Annual IC Time Burden (Hours)	13,260	13,260
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.