Information Collection

Profit/Nonprofit Business

IC 205111 under ICR 201208-0584-002 · OMB 0584-0580.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0584-0580 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
App.AA.1_Eng.Hospital Data Request.docx	Other-Hospital Data Request Form
App.AA.2_Span.Hospital Data Request.docx	Other-Hospital Data Request Form-Spa
App.CC.1_Eng.Provider Data Request.docx	Other-Provider Data Request
App.CC.2_Span.Provider Data Request.docx	Other-Provider Data Request-Spanish

IC Title:

Profit/Nonprofit Business

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	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Hospital Data Request Form	App.AA.1_Eng.Hospital Data Request.docx	Yes	Yes	Fillable Fileable
Other-Hospital Data Request Form-Spanish	App.AA.2_Span.Hospital Data Request.docx	Yes	Yes	Fillable Fileable
Other-Provider Data Request	App.CC.1_Eng.Provider Data Request.docx	Yes	Yes	Fillable Fileable
Other-Provider Data Request-Spanish	App.CC.2_Span.Provider Data Request.docx	Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: Food and Nutrition Assistance

Privacy Act System of Records

Title: Privacy Act of 1974

FR Citation: 5 FR 552

Number of Respondents: 4,510

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 99 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,836	1,836
Annual IC Time Burden (Hours)	81	81
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.