Information Collection

Surveys of Safety Net Providers for the Healthy Communities Access Program Evaluation

IC 6551 under ICR 200501-0915-001 · OMB 0915-0296.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

Surveys of Safety Net Providers for the Healthy Communities Access Program Evaluation

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Migrated

Obligation to Respond: Voluntary

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

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 550

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 30 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	550	550
Annual IC Time Burden (Hours)	170	170
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.