Information Collection

Providers - State/Tribal

IC 178433 under ICR 201006-0930-002 · OMB 0930-0286.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0286 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Provider Instrumen Providers - State/Tribal	Form and Instruction
Provider Instrumen Provider Instruments A3 ST - Provider Instruments.pdf	Form and Instruction
A4 ST - Provider Supporting Documents.pdf Provider Supporting Documents	IC Document

IC Title:

Providers - State/Tribal

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
Form and Instruction	Provider Instruments	Provider Instruments	A3 ST - Provider Instruments.pdf		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 97,972

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

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	391,888	391,742	146
Annual IC Time Burden (Hours)	17,379	17,269	110
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Provider Supporting Documents	A4 ST - Provider Supporting Documents.pdf	06/02/2010

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