Information Collection

Healthcare Coalition Questionnaire

IC 203649 under ICR 201203-0990-001 · OMB 0990-0391.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0990-0391 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
HCQ_OMBSubmit_073112.pdf	Other-Questionnaire
Final HPP Generic Clearance Submission Template - Healthcare Coaltion8-1-12.doc Mini supporting statement	IC Document

IC Title:

Healthcare Coalition Questionnaire

Agency IC Tracking Number:

IC Status: New

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
Other-Questionnaire			HCQ_OMBSubmit_073112.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 62

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	62	62
Annual IC Time Burden (Hours)	62	62
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Mini supporting statement	Final HPP Generic Clearance Submission Template - Healthcare Coaltion8-1-12.doc	08/08/2012

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.