Healthcare Coalition Questionnaire

The Hospital Preparedness Program

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

IC Title:	Healthcare Coalition Questionnaire	Agency IC Tracking Number:

IC Status: New

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
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 %

	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

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.