Information Collection

Application for Certification as a Federally Qualified Health Center Look-Alike

IC 6372 under ICR 200508-0915-003 · OMB 0915-0142.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0142 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	Application for Certification as a Federally Qualified Health Center Look-Alike	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.	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: 140	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	140	40	100
Annual IC Time Burden (Hours)	5,500	1,500	4,000
Annual IC Cost Burden (Dollars)	0	-1,000	1,000

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.