Information Collection

Individualized Quality Control Plan Workbook Survey

IC 227194 under ICR 201606-0920-007 · OMB 0920-0974.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
03_IQCPEpiInfosurveytool_05-04-2017.pdf	Other-Online
02_Invitation to participate IQCP 05-04-2017.docx	Other-Email
01_Request for approval form IQCP05-04-2017.docx Request for Approval	IC Document

IC Title:

Agency IC Tracking Number:

0920-17AQI

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-Online					Yes	Yes	Fillable Fileable
Other-Email					Yes	Yes	Printable Only

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: 100 %

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
Request for Approval		06/15/2017

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

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