Information Collection

Individualized Quality Control Plan Workbook Survey

IC 225310 under ICR 201606-0920-007 · OMB 0920-0974.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0974 Individualized Quality Control Plan Workbook Survey	Form
02_Invitation to participate IQCP 01-24-2017.docx	Instruction
0920-0974 03_Screen shots of IQCP Workbook Survey 01-19-2017 03_Screen shots of IQCP Workbook Survey 01-19-2017.pdf	Form
01_Request for approval form IQCP 01-24-2017.docx 01_Request for approval form IQCP 01-24-2017	IC Document

IC Title:

Agency IC Tracking Number:

17NR

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
Form	0920-0974	03_Screen shots of IQCP Workbook Survey 01-19-2017	03_Screen shots of IQCP Workbook Survey 01-19-2017.pdf		Yes	Yes	Fillable Printable
Instruction			02_Invitation to participate IQCP 01-24-2017.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 500

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: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	84	84
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
01_Request for approval form IQCP 01-24-2017	01_Request for approval form IQCP 01-24-2017.docx	01/25/2017

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