Need for Assitance Worksheet

The Health Center Program Application Forms

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0285 can be found here:

Documents and Forms

Document Name Document Type
Form 9 Need for Assitance Worksheet Form
9 Need for Assistance Worksheet Form 9 (track changes).doc Form
9 Need for Assistance Worksheet Final Form 9 - 2017.docx Form

Information Collection (IC) Details

IC Title:	Need for Assitance Worksheet	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	9	Need for Assistance Worksheet	Form 9 (track changes).doc		Yes	Yes	Fillable Fileable
Form	9	Need for Assistance Worksheet Final	Form 9 - 2017.docx		Yes	Yes	Fillable Fileable

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: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	500	-150	650
Annual IC Time Burden (Hours)	2,250	-1,000	3,250
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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