Information Collection

Checklist for Deleting Existing Service Delivery Site

IC 193526 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form 30 Checklist for Deleting Existing Service Delivery Site	Form and Instruction
30 Checklist for Deleting Existing Service Delivery Site - Checklist for Deleting Existing Service Delivery Site - track changes.docx	Form and Instruction
30 Checklist for Deleting Existing Service Delivery Site 20 Checklist for Deleting Existing Service Delivery Site 2017.docx	Form and Instruction

IC Title:

Checklist for Deleting Existing 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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	30	Checklist for Deleting Existing Service Delivery Site - track changes	Checklist for Deleting Existing Service Delivery Site - track changes.docx		Yes	Yes	Fillable Fileable
Form and Instruction	30	Checklist for Deleting Existing Service Delivery Site 2017 Final	Checklist for Deleting Existing 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 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	700	0	700
Annual IC Time Burden (Hours)	700	-700	1,400
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.