Information Collection

Health Systems Agency Application Guidelines For Designation And Grant And Related Reporting Requirements

IC 112137 under ICR 198310-0935-001 · OMB 0935-0071.

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IC Title:

HEALTH SYSTEMS AGENCY APPLICATION GUIDELINES FOR DESIGNATION AND GRANT AND RELATED REPORTING REQUIREMENTS

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	PHS-5161	No	No
Form	HRA-217	No	No
Form	HRA-2172	No	No

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 131

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	131	131
Annual IC Time Burden (Hours)	6,550	6,550
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.

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