Consolidated FFR

DATA Act Section 5 Grants Pilot

Documents and Forms

Document Name Document Type
HHS DAP_Consolidated FFR Discussion Survey 06242016.docx Other-Survey
4040-0017_Short Supporting Statement CFFR Discussion_060816.docx Short Supporting Statement IC Document
4040-0017_SupportingStatement A CFFR Discussion_06082016.docx Supporting Statement A IC Document
DRAFT_HHS DAP CFFR Discussion_v3_Draft_06242016.pptx CFFR Discussion PowerPoint Presentation IC Document

Information Collection (IC) Details

IC Title:	Consolidated FFR	Agency IC Tracking Number:

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-Survey			HHS DAP_Consolidated FFR Discussion Survey 06242016.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 90	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	90	90
Annual IC Time Burden (Hours)	15	15
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Short Supporting Statement	4040-0017_Short Supporting Statement CFFR Discussion_060816.docx	06/24/2016
Supporting Statement A	4040-0017_SupportingStatement A CFFR Discussion_06082016.docx	06/24/2016
CFFR Discussion PowerPoint Presentation	DRAFT_HHS DAP CFFR Discussion_v3_Draft_06242016.pptx	06/24/2016

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.