HRSA Client-Level Data Reporting System: Service Provider Report

HRSA HAB Client-Level Data Reporting System

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0323 can be found here:

Documents and Forms

Document Name Document Type
Form C HRSA Client-Level Data Reporting System: Service Provider Report Form
C C - 2017_Service_Provider_Form_Screenshots.docx C - 2017_Service_Provider_Form_Screenshots.docx Form

Information Collection (IC) Details

IC Title:	HRSA Client-Level Data Reporting System: Service Provider Report	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	C	C - 2017_Service_Provider_Form_Screenshots.docx	C - 2017_Service_Provider_Form_Screenshots.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,793	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	1,793	1,793
Annual IC Time Burden (Hours)	30,481	30,481
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.