Information Collection

BCRS Collegiate Health Service Corps Survey

IC 199895 under ICR 200904-0915-002 · OMB 0915-0212.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0212 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CHSC1 BCRS Collegiate Health Service Corps Survey	Form
CHSC1 CHSC Survey AHECNATION_CHSC_Application.pdf	Form
AHECNATION_CHSC_Application.jpg CHSC Survey Screenshots	IC Document
BCRS-CHSC Survey-Draft-Supporting Statement-4.13.11.docx Supporting Statement	IC Document

IC Title:

BCRS Collegiate Health Service Corps Survey

Agency IC Tracking Number:

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
Form	CHSC1	CHSC Survey	AHECNATION_CHSC_Application.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	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	1,500	0	0	0	0	0
Annual IC Time Burden (Hours)	750	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CHSC Survey Screenshots	AHECNATION_CHSC_Application.jpg	10/21/2011
Supporting Statement	BCRS-CHSC Survey-Draft-Supporting Statement-4.13.11.docx	10/21/2011

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