Information Collection

Cost Assessment Tool

IC 179138 under ICR 201304-0920-004 · OMB 0920-0745.

Documents and Forms

Document Name Document Type
Attachment 5b. Cost Assessment Tool Users Guide.docx Other-Cost Assessment Tool
Attachment 5a. Cost Assessment Tool Web portal.docx Other-Entrance to Web Portal Screen

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Cost Assessment Tool	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
Other-Cost Assessment Tool			Attachment 5b. Cost Assessment Tool Users Guide.docx		Yes	Yes	Fillable Fileable
Other-Entrance to Web Portal Screen Shot			Attachment 5a. Cost Assessment Tool Web portal.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 29	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	29	3	26
Annual IC Time Burden (Hours)	638	66	572
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.