Information Collection

Health and Healthcare Organization Screener Survey

IC 214391 under ICR 201412-0990-002 · OMB 0990-0429.

Documents and Forms

Document Name Document Type
0990-Health and Health Care Organization Screener Survey_June 1 2015.docx Other-screener

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Health and Healthcare Organization Screener Survey	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
Other-screener			0990-Health and Health Care Organization Screener Survey_June 1 2015.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50,000	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	50,000	50,000
Annual IC Time Burden (Hours)	4,167	4,167
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.