The Health Center Program Application Forms

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0285 can be found here:

Documents and Forms

Document Name Document Type
Form 0285 ftca form The Health Center Program Application Forms Form
0285 ftca form 0285 ftca form 0285 FTCA.doc Form
0285 ftca background.pdf 0285 ftca background info IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	The Health Center Program Application Forms	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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
Form	0285 ftca form	0285 ftca form	0285 FTCA.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 800	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
Annual Number of Responses for this IC	800	800
Annual IC Time Burden (Hours)	800	800
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
0285 ftca background info	0285 ftca background.pdf	06/15/2007

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.