Service Sites

The Health Center Program Application Forms

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0285 can be found here:

Documents and Forms

Document Name Document Type
Form 5b Service Sites Form
5b Service Sites 08. Form 5B - Service Sites.doc Form

Information Collection (IC) Details

IC Title:	Service Sites	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
Form	5b	Service Sites	08. Form 5B - Service Sites.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,600	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,600	566	1,034
Annual IC Time Burden (Hours)	1,600	566	1,034
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.