Information Collection

Cost Assessment Tool

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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Cost Assessment Tool					Yes	Yes	Fillable Fileable
Other-Entrance to Web Portal Screen Shot					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 %

table that charts list of burden
	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

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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