Information Collection

HAB Client-Level Provider Report

IC 187334 under ICR 201101-0915-002 · OMB 0915-0323.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0323 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2 HAB Client-Level Provider Report	Form and Instruction
2 Service Provider Report C - 2010_Service_Provider_Form_Screenshots.doc	Form and Instruction

IC Title:

HAB Client-Level Provider Report

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	2	Service Provider Report	C - 2010_Service_Provider_Form_Screenshots.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,080

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,080	-751	-173	3,004
Annual IC Time Burden (Hours)	4,784	-1,850	-426	7,060
Annual IC Cost Burden (Dollars)	0	0	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.