Information Collection

State Offices of Rural Health TA Data Collection Form

IC 186810 under ICR 201307-0915-004 · OMB 0915-0322.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0322 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 State Offices of Rural Health TA Data Collection Form	Form and Instruction
1 TA Request Form SORH TA PIMS Screenshot.doc	Form and Instruction
SORH TA Trend Report Example.pdf SORH TA Trend Report Example	IC Document
SORH PIMS Report.pdf SORH PIMS Report	IC Document

IC Title:

State Offices of Rural Health TA Data Collection Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

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	TA Request Form	SORH TA PIMS Screenshot.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50

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	Previously Approved
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	625	625
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SORH TA Trend Report Example	SORH TA Trend Report Example.pdf	06/25/2013
SORH PIMS Report	SORH PIMS Report.pdf	06/25/2013

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