Information Collection

Hospital Institutional Planning Questionnaire

IC 112673 under ICR 198106-0938-006 · OMB 0938-0054.

Documents and Forms

Document Name Document Type

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Information Collection (IC) Details

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IC Title:	HOSPITAL INSTITUTIONAL PLANNING QUESTIONNAIRE	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
Form	SSA-3213				No	No
Form	HCFA-3213				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 6,650	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	6,650	6,650
Annual IC Time Burden (Hours)	3,325	3,325
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded

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