Information Collection

Provider

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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.