Information Collection

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

IC 6372 under ICR 200810-0915-003 · OMB 0915-0142.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form FQHCLA - 1 Application for Certification as a Federally Qualified Health Center Look-Alike	Form and Instruction
FQHCLA - 1 FQHC Look Alike PIN Program Information Notice - 2003-21 - 10-9-08.pdf bphc.hrsa.gov/policy/	Form and Instruction

IC Title:

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	FQHCLA - 1	FQHC Look Alike PIN	Program Information Notice - 2003-21 - 10-9-08.pdf	http://bphc.hrsa.gov/policy/	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

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 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	140	140
Annual IC Time Burden (Hours)	5,500	5,500
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.