Letter of Intent

ARRA Section 3013 Supporting Statement for State Health Information Exchange Cooperative Agreement Program

Documents and Forms

Document Name Document Type
Form 1 Letter of Intent Form
1 LOI Attachment to 3013-Letter of Intent.doc Form

Information Collection (IC) Details

IC Title:	Letter of Intent	Agency IC Tracking Number:

Is this a Common Form?		IC Status: New

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	1	LOI	Attachment to 3013-Letter of Intent.doc		Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	500	500
Annual IC Cost Burden (Dollars)	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.