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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form 1 Ryan White CARE Act Dental Reimbursement Program Form
2011DSRInstructions032210.pdf Instruction
1 dental services form 2011DSRForm032210.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.