Information Collection

Provider

IC 207369 under ICR 201306-0990-001 · OMB 0990-0409.

Documents and Forms

Document Name Document Type
0990-RW Study Appendix E - Advance Letter_06-14-13.docx Other-interview
0990-RW Study Appendix G - Provider guide_06-14-13.docx Other-guide
0990-RW Study Appendix A - Relevant Sections ofACA.PDF 0990-RW Study Appendix A - Relevant Sections ofACA IC Document
0990-RW Study Appendix D - Responses to Comments_06-14-13.docx 0990-RW Study Appendix D - Responses to Comments_06-14-13 IC Document
0990-RW Study Appendix C - Public Comments_06-14-13.pdf 0990-RW Study Appendix C - Public Comments_06-14-13 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Provider	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-interview			0990-RW Study Appendix E - Advance Letter_06-14-13.docx		No	No	Paper Only
Other-guide			0990-RW Study Appendix G - Provider guide_06-14-13.docx		No	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 133	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	133	133
Annual IC Time Burden (Hours)	122	122
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
0990-RW Study Appendix A - Relevant Sections ofACA	0990-RW Study Appendix A - Relevant Sections ofACA.PDF	06/14/2013
0990-RW Study Appendix D - Responses to Comments_06-14-13	0990-RW Study Appendix D - Responses to Comments_06-14-13.docx	06/14/2013
0990-RW Study Appendix C - Public Comments_06-14-13	0990-RW Study Appendix C - Public Comments_06-14-13.pdf	06/14/2013

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