Information Collection

Health Systems Agency Application Guidelines For Designation And Related Reporting Requirements

IC 110262 under ICR 198511-0915-001 · OMB 0915-0085.

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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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HRA 217				No	No
Form	217-2				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	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

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.