Information Collection

Form for community agency points of contact to verify agency information (monthly)

IC 226035 under ICR 201701-0990-004 · OMB 0990-0458.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0990-0458 can be found here:

Documents and Forms

Document Name Document Type
Agency POC Information Form DVHF.docx Other-listed

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Form for community agency points of contact to verify agency information (monthly)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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
Other-listed			Agency POC Information Form DVHF.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	48	48
Annual IC Time Burden (Hours)	12	12
Annual IC Cost Burden (Dollars)	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.