Information Collection

Application

IC 7545 under ICR 201210-0930-002 · OMB 0930-0168.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0168 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Certifications Application	Form and Instruction
Public Burden Statement.doc	Instruction
Planning Planning BG application 5-21-13 FINAL.pdf	Form and Instruction
Reporting Reporting 2014_BGrepts_4-29-13 clean.pdf	Form and Instruction
Certifications Certifications Attachment A3 - Certifications.pdf	Form and Instruction
Attachment C - Responses.pdf Responses	IC Document
Attachment B - Comments.pdf Comments	IC Document

IC Title:

Application

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Certifications	Certifications	Attachment A3 - Certifications.pdf	Yes	Yes	Fillable Printable
Instruction			Public Burden Statement.doc	Yes	Yes	Printable Only
Form and Instruction	Planning	Planning	BG application 5-21-13 FINAL.pdf	Yes	Yes	Fillable Printable
Form and Instruction	Reporting	Reporting	2014_BGrepts_4-29-13 clean.pdf	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 119

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	119	119
Annual IC Time Burden (Hours)	37,429	37,429
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Responses	Attachment C - Responses.pdf	10/10/2012
Comments	Attachment B - Comments.pdf	10/10/2012

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