Information Collection

Service Sites

IC 180777 under ICR 201312-0915-005 · OMB 0915-0285.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 5b Service Sites	Form
5b Service Sites 08. Form 5B - Service Sites.doc	Form

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:

table that charts list of 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 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	1,600	1,600
Annual IC Time Burden (Hours)	1,600	1,600
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.