PHC Non-Labor Cost Questionnaire

Positive Health Check Evaluation Trial

Documents and Forms

Document Name Document Type
PHC Non-Labor Cost Questionnaire Form and Instruction
PHC Non-Labor Cost Questionnaire - Att 17 Att 17 PHC non-labor cost questionnaire06.14.17.docx Form and Instruction

Information Collection (IC) Details

IC Title:	PHC Non-Labor Cost Questionnaire	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
Form and Instruction	NA	PHC Non-Labor Cost Questionnaire - Att 17	Att 17 PHC non-labor cost questionnaire06.14.17.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

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)	24	24
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.