Information Collection

RFCC Clinical Intake Form (Provider RFCCs)

IC 180721 under ICR 200706-0990-003 · OMB 0990-0316.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Appendix F-1_women's health registration_Utah_8-7-06.doc	Other-form
Appendix F-2_women's health registration_TN_8-7-06.doc	Other-form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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
Other-form			Appendix F-1_women's health registration_Utah_8-7-06.doc		No	No	Fillable Printable
Other-form			Appendix F-2_women's health registration_TN_8-7-06.doc		No	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 200

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	67	67
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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