Information Collection

Application To Participate In The Public Health Capitation Program, 42 Cfr 57

IC 110271 under ICR 198901-0915-001 · OMB 0915-0089.

Documents and Forms

Documents and forms in this information collection
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IC Title:

APPLICATION TO PARTICIPATE IN THE PUBLIC HEALTH CAPITATION PROGRAM, 42 CFR 57

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	HRSA-528				No	No

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 26

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	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	52	52
Annual IC Time Burden (Hours)	182	182
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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