Information Collection

PSH Self-Assessment

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

Documents and Forms

Documents and forms in this information collection
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

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:

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.