Information Collection

6 Month Report

IC 214904 under ICR 201502-0925-001 · OMB 0925-0714.

Documents and Forms

Document Name Document Type
Form 1 6 Month Report Form and Instruction
1 6 Month Report Attachment 1A 6 Month Report.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	6 Month Report	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	1	6 Month Report	Attachment 1A 6 Month Report.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 15	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	15	15
Annual IC Time Burden (Hours)	23	23
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.