Information Collection

NHSC Site Retention Assessment Questionnaire

IC 205949 under ICR 201302-0915-002 · OMB 0915-0372.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 NHSC Site Retention Assessment Questionnaire NHSC Site Retention Assessment Questionnaire	Form and Instruction
1 NHSC Site Retention Assessment Questionnaire NHSC Site Retention Assessment Questionnaire_FINAL_amended_12132013.pdf	Form and Instruction

IC Title:

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	1				No		Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,000

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	7,000	7,000
Annual IC Time Burden (Hours)	3,549	3,549
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.

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