Information Collection

Board Chairs

IC 202519 under ICR 201205-0925-005 · OMB 0925-0662.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 3 Board Chairs	Form and Instruction
3 Chair Questionaire Attachment #3 CSSC Chair Questionnaire.docx	Form and Instruction
5a Assessment Screens Chairs Attachment #5a-Draft CSSC Assessment Screens Final CHAIRS.docx	Form and Instruction

IC Title:

Board Chairs

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

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	3	Chair Questionaire	Attachment #3 CSSC Chair Questionnaire.docx		Yes	Yes	Printable Only
Form and Instruction	5a	Assessment Screens Chairs	Attachment #5a-Draft CSSC Assessment Screens Final CHAIRS.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 11

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	11	11
Annual IC Time Burden (Hours)	4	4
Annual IC Cost Burden (Dollars)	0	0

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.