Information Collection

National Health Service Corps Site Survey

IC 6473 under ICR 201112-0915-003 · OMB 0915-0232.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form 1 National Health Service Corps Site Survey	Form and Instruction
Form 1 NHSC Site Survey NHSC Site Survey_12022011.docx	Form and Instruction

IC Title:

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	Form 1	NHSC Site Survey	NHSC Site Survey_12022011.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,200

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	Previously Approved
Annual Number of Responses for this IC	1,200	1,200
Annual IC Time Burden (Hours)	32,400	32,400
Annual IC Cost Burden (Dollars)	105,000	105,000

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.