Information Collection

Attachment A.2.14 Data Form Section 4 Report Once

IC 215746 under ICR 201503-0925-001 · OMB 0925-0718.

Documents and Forms

Document Name Document Type
Form 12 Attachment A.2.14 Data Form Section 4 Report Once Form and Instruction
12 Data Form Section 4 report once A.2.14-Data Form Section 4 Report Once.xlsx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Attachment A.2.14 Data Form Section 4 Report Once	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	12	Data Form Section 4 report once	A.2.14-Data Form Section 4 Report Once.xlsx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 17	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	17	17
Annual IC Time Burden (Hours)	9	9
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.