Information Collection

Consolidated FFR

IC 222174 under ICR 201603-4040-001 · OMB 4040-0017.

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Consolidated FFR

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

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
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 %

table that charts list of burden
	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

table that charts IC Documents
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.