Information Collection

Single Audit Form Completion Test Model

IC 223089 under ICR 201603-4040-001 · OMB 4040-0017.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
HHS DAP_Single Audit Questionnaire_08112016.docx	Other-questionnaire
REVISED_4040-0017_Short Supporting Statement_Single Audit SEFA_081716.docx Short SS	IC Document
4040-0017_Supporting Statement A_Single Audit SEFA_08112016.docx Suppt. st A	IC Document
HHS DAP_Single Audit Form Completion_08112016.pptx audit form completion	IC Document
HHS DAP_Single Audit Form Completion_Instruction Manual_08112016.docx instructions	IC Document

IC Title:

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-questionnaire			HHS DAP_Single Audit Questionnaire_08112016.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 42

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

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	42	42
Annual IC Time Burden (Hours)	11	11
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Short SS	REVISED_4040-0017_Short Supporting Statement_Single Audit SEFA_081716.docx	08/17/2016
Suppt. st A	4040-0017_Supporting Statement A_Single Audit SEFA_08112016.docx	08/17/2016
audit form completion	HHS DAP_Single Audit Form Completion_08112016.pptx	08/17/2016
instructions	HHS DAP_Single Audit Form Completion_Instruction Manual_08112016.docx	08/17/2016

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