Information Collection

PSH Self-Assessment

IC 208314 under ICR 201701-0930-003 · OMB 0930-0339.

Documents and Forms

Document Name Document Type
Form PSH_Self-Assessmen PSH Self-Assessment Form and Instruction
PSH_Self-Assessmen PSH_Self-Assessment Attachment 4_PSH_Self-Assessment.pdf Form and Instruction
Attachment 09_PSH Web Consent.docx PSH Web Consent. IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	PSH Self-Assessment	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

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	PSH_Self-Assessment	PSH_Self-Assessment	Attachment 4_PSH_Self-Assessment.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 36	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	36	-64	100
Annual IC Time Burden (Hours)	24	-43	67
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
PSH Web Consent.	Attachment 09_PSH Web Consent.docx	08/19/2013

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