Information Collection

Quarterly Health Center Perfoemance Measure Reporting Tool

IC 222375 under ICR 201703-0920-010 · OMB 0920-1156.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1156 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Quarterly Health Center Perfoemance Measure Reporting Tool	Form and Instruction
Quarterly Health Center Performance Measure Reporting To Att 7 Quarterly Health Center Performance Measure Reporting Tool.docx	Form and Instruction

IC Title:

Quarterly Health Center Perfoemance Measure Reporting Tool

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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	NA	Quarterly Health Center Performance Measure Reporting Tool	Att 7 Quarterly Health Center Performance Measure Reporting Tool.docx	NA	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: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	12	12
Annual IC Time Burden (Hours)	48	48
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.