Information Collection

National Health Service Corps Site Survey

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	National Health Service Corps Site Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection 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 %

	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

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.