Full Application Required Data Elements

Section 3012 Health Information Technology Extension Program: Full Application

Documents and Forms

Document Name Document Type
Form 1 Full Application Required Data Elements Form and Instruction
1 Attachment 1 3012 PRA Full Ap Attachment 1 8.26.2009.doc Form and Instruction

Information Collection (IC) Details

IC Title:	Full Application Required Data Elements	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 and Instruction	1	Attachment 1	3012 PRA Full Ap Attachment 1 8.26.2009.doc		Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 180	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	180	180
Annual IC Time Burden (Hours)	50,400	50,400
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.