Information Collection

Annual Report

IC 193865 under ICR 201101-0938-004 · OMB 0938-1101.

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IC Title:

Annual Report

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	51	-5	56
Annual IC Time Burden (Hours)	226,134	-22,170	248,304
Annual IC Cost Burden (Dollars)	11,484,041	3,530,137	7,953,904

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