Information Collection

Notice of Award -- Proof of Concept Test

IC 223704 under ICR 201603-4040-001 · OMB 4040-0017.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
4040-0017 HHS NOA Questionnaire_09232016.docx	Other-questionnaire
Group A - Standardized NOAs 09232016.pdf Group A Standardized NOA	IC Document
Group B - Non-Standardized NOAs 09232016.pdf Group B Non-Standardized NOAs	IC Document
Group A DCT Answer Key_09232016.docx Group A Answer Key	IC Document
Group B DCT Answer Key_09232016.docx Group B Answer Key	IC Document
NOA Webinar Deck_09232016.pptx Webinar Deck	IC Document
NOA Instructions and DCT_09232016.docx Instructions	IC Document
4040-0017_Short Supporting Statement_NOA_09232016.docx Short Supporting Statement	IC Document
4040-0017_Supporting Statement A_NOA_09232016.docx Supporting Statement A	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			4040-0017 HHS NOA Questionnaire_09232016.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

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	100	100
Annual IC Time Burden (Hours)	33	33
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Group A Standardized NOA	Group A - Standardized NOAs 09232016.pdf	09/26/2016
Group B Non-Standardized NOAs	Group B - Non-Standardized NOAs 09232016.pdf	09/26/2016
Group A Answer Key	Group A DCT Answer Key_09232016.docx	09/26/2016
Group B Answer Key	Group B DCT Answer Key_09232016.docx	09/26/2016
Webinar Deck	NOA Webinar Deck_09232016.pptx	09/26/2016
Instructions	NOA Instructions and DCT_09232016.docx	09/26/2016
Short Supporting Statement	4040-0017_Short Supporting Statement_NOA_09232016.docx	09/26/2016
Supporting Statement A	4040-0017_Supporting Statement A_NOA_09232016.docx	09/26/2016

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