Information Collection

Small Health Care Provider Quality Improvement Grant Program

IC 184012 under ICR 201103-0915-002 · OMB 0915-0319.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0319 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 4 Small Health Care Provider Quality Improvement Grant Program	Form and Instruction
4 Small Health Care Provider Quality Improvement Quality Program PIMS Measures--FINAL.docx	Form and Instruction

IC Title:

Small Health Care Provider Quality Improvement Grant Program

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
Form and Instruction	4	Small Health Care Provider Quality Improvement	Quality Program PIMS Measures--FINAL.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 59

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	59	44	15
Annual IC Time Burden (Hours)	472	457	15
Annual IC Cost Burden (Dollars)	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.