Ryan White CARE Act Dental Reimbursement Program

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0151 can be found here:

Documents and Forms

Document Name Document Type
Form dental 1 Ryan White CARE Act Dental Reimbursement Program Form
0151 instructions.doc Instruction
dental 1 dental 0151 dental report.doc Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Ryan White CARE Act Dental Reimbursement Program	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	dental 1	dental	0151 dental report.doc		Yes	Yes	Fillable Fileable
Instruction			0151 instructions.doc		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 80	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	80	-45	125
Annual IC Time Burden (Hours)	1,600	-900	2,500
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.