Information Collection

Rural Health Care Program

IC 219023 under ICR 201402-3060-011 · OMB 3060-1149.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3060-1149 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
RHC_Survey_v4 rk.docx	Other-Survey
Generic Clearance Submission Template Small Discussion Group Feedback (final).docx General Clearance Submission Template Small Group Discussion	IC Document
Generic Clearance Submission Template RHC customer satisfication survey (final).docx General Clearance Submission Template RHC Survey	IC Document
Generic Clearance Submission Template RHC usability testing (final).docx General Clearance Submission Template RHC Usability Testing	IC Document

IC Title:

Rural Health Care Program

Agency IC Tracking Number:

WCB

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
Other-Survey			RHC_Survey_v4 rk.docx		Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,535

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 90 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	5,535	5,535
Annual IC Time Burden (Hours)	2,890	2,890
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
General Clearance Submission Template Small Group Discussion	Generic Clearance Submission Template Small Discussion Group Feedback (final).docx	11/20/2015
General Clearance Submission Template RHC Survey	Generic Clearance Submission Template RHC customer satisfication survey (final).docx	11/20/2015
General Clearance Submission Template RHC Usability Testing	Generic Clearance Submission Template RHC usability testing (final).docx	11/20/2015

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