Information Collection

Hospital Campaign Activity Scorecard

IC 209057 under ICR 201310-0915-001 · OMB 0915-0373.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0373 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Hospital Campaign Activity Scorecard Hospital Campaign Activity Scorecard	Form and Instruction
1 Hospital Campaign Activity Scorecard ChallengeScorecard_Form_090513.pdf	Form and Instruction

IC Title:

Hospital Campaign Activity Scorecard

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	1				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,000

Number of Respondents for Small Entity: 500

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	1,000	1,000
Annual IC Time Burden (Hours)	367	367
Annual IC Cost Burden (Dollars)	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.

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