Information Collection

ATTACHMENT F - Monthly Check-In

IC 213580 under ICR 201410-0935-002 · OMB 0935-0228.

Documents and Forms

Document Name Document Type
Form 3 ATTACHMENT F - Monthly Check-In Form and Instruction
3 ATTACHMENT F - Monthly Check-In Attachment F - Monthly Check-In.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	ATTACHMENT F - Monthly Check-In	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	3	ATTACHMENT F - Monthly Check-In	Attachment F - Monthly Check-In.docx		No		Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 20	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	120	120
Annual IC Time Burden (Hours)	60	60
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.