OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Profit/Nonprofit Business

IC 205111 under ICR 201404-0584-005 · OMB 0584-0580.

Documents and Forms
Document Name
Document Type
Other-Hospital Data Request Form
Other-Hospital Data Request Form-Spa
Other-Provider Data Request
Other-Provider Data Request-Spanish
Information Collection (IC) Details

View Information Collection (IC)

Profit/Nonprofit Business
 
No Unchanged
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Hospital Data Request Form App.AA.1_Eng.Hospital Data Request.docx Yes Yes Fillable Fileable
Other-Hospital Data Request Form-Spanish App.AA.2_Span.Hospital Data Request.docx Yes Yes Fillable Fileable
Other-Provider Data Request App.CC.1_Eng.Provider Data Request.docx Yes Yes Fillable Fileable
Other-Provider Data Request-Spanish App.CC.2_Span.Provider Data Request.docx Yes Yes Fillable Fileable

Income Security Food and Nutrition Assistance

Privacy Act of 1974  5 FR 552

4,510 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   99 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 1,836 0 0 0 0 1,836
Annual IC Time Burden (Hours) 81 0 0 0 0 81
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.