Information Collection

NSRCF - Facility Screener Questionnaire

IC 183887 under ICR 200911-0920-003 · OMB 0920-0780.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment G-Facility Screener.doc	Other-WORD
Attachment F-Advance Package.doc Attachment F-Advance Package	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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
Other-WORD			Attachment G-Facility Screener.doc		No	No	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Health Resources Utilization Statistics

FR Citation: 49 FR 37697

Number of Respondents: 1,125

Number of Respondents for Small Entity: 10

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,125	1,100	25
Annual IC Time Burden (Hours)	188	182	6
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment F-Advance Package	Attachment F-Advance Package.doc	10/20/2009

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