Full Application Required Data Elements

Section 3013 State Health Information Exchange Cooperative Agreement Program: Full Application

Documents and Forms

Document Name Document Type
Form 1 Full Application Required Data Elements Form and Instruction
1 Attachment 1 PRA Review for Emergency Request for 3013 Application 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? No		IC Status: Unchanged

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	PRA Review for Emergency Request for 3013 Application 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: 50	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	14,000	14,000
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.