Information Collection

Ryan White CARE Act Dental Reimbursement Program

IC 6384 under ICR 201104-0915-002 · OMB 0915-0151.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0151 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Ryan White CARE Act Dental Reimbursement Program	Form
2011DSRInstructions032210.pdf	Instruction
1 dental services form 2011DSRForm032210.pdf	Form

IC Title:

Ryan White CARE Act Dental Reimbursement 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	1	dental services form	2011DSRForm032210.pdf		Yes	Yes	Fillable Fileable
Instruction			2011DSRInstructions032210.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 70

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	70	-10	80
Annual IC Time Burden (Hours)	1,400	-200	1,600
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.