Information Collection

Attachment A: Baseline Practice Assessment

IC 224203 under ICR 201610-0935-001 · OMB 0935-0235.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Attachment A: Baseline Practice Assessment	Form and Instruction
1 Appendix A: Baseline Practice Assessment Appendix A_ Baseline_Assessment_rev_20161031.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

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 and Instruction	1	Appendix A: Baseline Practice Assessment	Appendix A_ Baseline_Assessment_rev_20161031.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 12

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

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	12	12
Annual IC Time Burden (Hours)	12	12
Annual IC Cost Burden (Dollars)	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.