Information Collection

Form C-Semi Annual Report Screen Shot

IC 203539 under ICR 201703-0938-014 · OMB 0938-1016.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1016 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form FORM C Form C-Semi Annual Report Screen Shot	Form
FORM C SEMI ANNUAL Report e-signature Connexion - Form C_esignature.pdf	Form
FORM C Semi Annual Report Screen Shot 1 Connexion - Form C1.pdf	Form and Instruction
FORM C Semi Annual Report Screen Shot 2 Connexion - Form C2.pdf	Form and Instruction

IC Title:

Form C-Semi Annual Report Screen Shot

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 414.410

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	FORM C	SEMI ANNUAL Report e-signature	Connexion - Form C_esignature.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	FORM C	Semi Annual Report Screen Shot 1	Connexion - Form C1.pdf	Yes	Yes	Fillable Fileable Signable
Form and Instruction	FORM C	Semi Annual Report Screen Shot 2	Connexion - Form C2.pdf	Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,594

Number of Respondents for Small Entity: 1,116

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	3,188	694	2,494
Annual IC Time Burden (Hours)	625	-206	831
Annual IC Cost Burden (Dollars)	0	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.