Information Collection

PSH Self-Assessment

IC 208314 under ICR 201308-0930-002 · OMB 0930-0339.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0339 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form PSH Self-Assessmen PSH Self-Assessment	Form and Instruction
PSH Self-Assessmen PSH Self-Assessment Attachment 04_PSH Self-Assessment.docx	Form and Instruction
Attachment 09_PSH Web Consent.docx PSH Web Consent.	IC Document

IC Title:

PSH Self-Assessment

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
Form and Instruction	PSH Self-Assessment	PSH Self-Assessment	Attachment 04_PSH Self-Assessment.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	67	67
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
PSH Web Consent.	Attachment 09_PSH Web Consent.docx	08/19/2013

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