Information Collection

NSRCF - Faciility Questionnaire

IC 183890 under ICR 200911-0920-003 · OMB 0920-0780.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment I-Facility Questionnaire.doc	Other-WORD
Attachment L-Thank You Letters.doc Attachment L-Thank You Letters	IC Document
Attachment M-Refusal Conversion Letters.doc Attachment M-Refusal Conversion Letters	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 I-Facility Questionnaire.doc		Yes	Yes	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: 300

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,125	1,000	125
Annual IC Time Burden (Hours)	1,406	1,343	63
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment L-Thank You Letters	Attachment L-Thank You Letters.doc	10/21/2009
Attachment M-Refusal Conversion Letters	Attachment M-Refusal Conversion Letters.doc	10/21/2009

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