Information Collection

State Offices of Rural Health TA Data Collection Form

IC 186810 under ICR 201006-0915-001 · OMB 0915-0322.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0322 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 001_ORHP_SORH State Offices of Rural Health TA Data Collection Form	Form and Instruction
001_ORHP_SORH SORH TA Form SORH TA form_2010.pdf	Form and Instruction

IC Title:

State Offices of Rural Health TA Data Collection Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

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
Form and Instruction	001_ORHP_SORH	SORH TA Form	SORH TA form_2010.pdf		No	No	Fillable Fileable

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: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	625	625
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.