Information Collection

Health Center Controlled Networks Progress Reports

IC 205055 under ICR 201603-0915-005 · OMB 0915-0360.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Work Plan Health Center Controlled Networks Progress Reports	Form and Instruction
Form 2 Annual Progress Report Health Center Controlled Networks Progress Reports	Form and Instruction
1 Work Plan FINALWork Plan Template 03.21.16.xls	Form and Instruction
2 Annual Progress Report Annual Progress Report Template Final.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1				Yes	Yes	Fillable Fileable
Form and Instruction	2				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 86

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	86	26	60
Annual IC Time Burden (Hours)	2,382	720	1,662
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.

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