Information Collection

NSRCF - Facility Screener Questionnaire

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

Documents and Forms

Document Name Document Type
Attachment G-Facility Screener.doc Other-WORD
Attachment F-Advance Package.doc Attachment F-Advance Package IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	NSRCF - Facility Screener Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection 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 %

	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

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.