Information Collection

Health Systems Agency Application Guidelines For Designation And Related Reporting Requirements

IC 110261 under ICR 198408-0915-009 · OMB 0915-0085.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0085 can be found here:

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Information Collection (IC) Details

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IC Title:	HEALTH SYSTEMS AGENCY APPLICATION GUIDELINES FOR DESIGNATION 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:

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 %

	Approved	Previously Approved
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

Title	Document	Date Uploaded

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