Information Collection

CHGME Payment Program HRSA 100-2 and HRSA 100-3 Annual Report Forms

IC 182196 under ICR 201308-0915-001 · OMB 0915-0313.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 100-2 CHGME Payment Program HRSA 100-2 and HRSA 100-3 Annual Report Forms	Form and Instruction
hrsaform1004_2013.pdf	Other-hrsaform1004_2013
hrsaform1005_2013.pdf	Other-hrsaform1005_2013
100-2 HRSA 100-2 FY13 - Redesign HRSA 100-2 FY13 - Redesign.xlsm	Form and Instruction
100-3 HRSA 100-3_FY13 HRSA 100-3_FY13.xlsm	Form and Instruction

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	100-2	HRSA 100-2 FY13 - Redesign	HRSA 100-2 FY13 - Redesign.xlsm	Yes	Yes	Fillable Printable
Other-hrsaform1004_2013			hrsaform1004_2013.pdf	Yes	Yes	Fillable Printable
Form and Instruction	100-3	HRSA 100-3_FY13	HRSA 100-3_FY13.xlsm	Yes	Yes	Fillable Printable
Other-hrsaform1005_2013			hrsaform1005_2013.pdf	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 54

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

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	54	-2	56
Annual IC Time Burden (Hours)	3,996	-411	4,407
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.