Information Collection

Attachment J – Data collection instrument: Site Visit Assessment

IC 227747 under ICR 201707-0935-004 · OMB 0935-0239.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0239 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 5 Attachment J – Data collection instrument: Site Visit Assessment	Form and Instruction
5 Site visits Attachment J_Site visit Assessment_Data collection instrument_20170727.docx	Form and Instruction
Attachment I_Site visit assessment_Cover letter and reminder notice_20170727.docx Attachment I – Site visit assessment_Cover letter and reminder notice.docx	IC Document

IC Title:

Attachment J â Data collection instrument: Site Visit Assessment

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

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	5	Site visits	Attachment J_Site visit Assessment_Data collection instrument_20170727.docx		No		Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 40

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	320	320
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment I â Site visit assessment_Cover letter and reminder notice.docx	Attachment I_Site visit assessment_Cover letter and reminder notice_20170727.docx	07/28/2017

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.