Information Collection

Uncompensated Services Assurance Report

IC 6349 under ICR 201206-0915-005 · OMB 0915-0077.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 710 Uncompensated Services Assurance Report	Form and Instruction
710 Uncompensated Services Assurance Report HRSAForm710.pdf ftp://ftp.hrsa.gov/hillburton/servassure.pdf	Form and Instruction
AuthorizingLegislation-0077.pdf Authorizing legislation-PHS Act	IC Document
CurrentRegulations-0077.pdf Current Regulations-0077	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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	710	Uncompensated Services Assurance Report	HRSAForm710.pdf	ftp://ftp.hrsa.gov/hillburton/servassure.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 181

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	6,441	-2,432	8,873
Annual IC Time Burden (Hours)	10,786	-3,893	14,679
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Authorizing legislation-PHS Act	AuthorizingLegislation-0077.pdf	04/13/2009
Current Regulations-0077	CurrentRegulations-0077.pdf	04/13/2009

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