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Federal forms, ICRs, and supporting documents

Information Collection

RFCC Clinical Intake Form (Provider RFCCs)

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

Documents and Forms
Document Name
Document Type
Other-form
Other-form
Information Collection (IC) Details

View Information Collection (IC)

RFCC Clinical Intake Form (Provider RFCCs)
 
No New
 
Voluntary
 

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

Health Health Care Services

 

200 0
   
Individuals or Households
 
   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 200 0 200 0 0 0
Annual IC Time Burden (Hours) 67 0 67 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.