Information Collection

Uncompensated Services Assurance Report

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Uncompensated Services Assurance Report	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:

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 %

	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

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.