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Health Care Program Violations Notification Form
HEALTH CARE PROGRAM VIOLATIONS NOTIFICATION FORM
OMB: 0990-0141
IC ID: 167056
OMB.report
HHS/HHSDM
OMB 0990-0141
ICR 198904-0990-008
IC 167056
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0990-0141 can be found here:
1990-08-28 - Revision of a currently approved collection
Documents and Forms
Document Name
Document Type
no available documents/forms check other ICs listed under this ICR
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
HEALTH CARE PROGRAM VIOLATIONS NOTIFICATION FORM
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Migrated
Obligation to Respond:
Voluntary
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Federal Enterprise Architecture Business Reference Module
Line of Business:
Subfunction:
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
450
Number of Respondents for Small Entity:
0
Affected Public:
State, Local, and Tribal Governments
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
450
0
0
0
0
450
Annual IC Time Burden (Hours)
38
0
0
0
0
38
Annual IC Cost Burden (Dollars)
0
0
0
0
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.