Information Collection

Checklist for Adding a new Service Delivery Site

IC 193525 under ICR 201608-0915-003 · OMB 0915-0285.

⚠️ Notice: This information collection may be referencing outdated material.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 29 Checklist for Adding a new Service Delivery Site Form and Instruction
29 Checklist for Adding a New Service Delivery Site - track Checklist for Adding a New Service Delivery Site - track changes.docx Form and Instruction
29 Checklist for Adding a New Service Delivery Site 2017 Fi Checklist for Adding a New Service Delivery Site 2017.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Checklist for Adding a new Service Delivery Site	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 and Instruction	29	Checklist for Adding a New Service Delivery Site - track changes	Checklist for Adding a New Service Delivery Site - track changes.docx		Yes	Yes	Fillable Fileable
Form and Instruction	29	Checklist for Adding a New Service Delivery Site 2017 Final	Checklist for Adding a New Service Delivery Site 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: 700	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	700	0	700
Annual IC Time Burden (Hours)	1,050	-350	1,400
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.