Information Collection

Data Collection Report (Initial Submission)

IC 193767 under ICR 201007-0938-001 · OMB 0938-1097.

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IC Title:

Data Collection Report (Initial Submission)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 51

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	51	51
Annual IC Time Burden (Hours)	2,550	2,550
Annual IC Cost Burden (Dollars)	68,340	68,340

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