Information Collection

ADAP Grantee Report and Client Level Data Elements Report

IC 199933 under ICR 201708-0915-001 · OMB 0915-0345.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0345 can be found here:

Documents and Forms

Document Name Document Type
Form B ADAP Grantee Report and Client Level Data Elements Report Form
D - Instruction Manual 2016 ADR_11042016_FINAL_508.pdf Instruction
B B - ADR Grantee Report.docx B - ADR Grantee Report.docx Form
C C - ADR Client-Level Data Elements 2017.docx C - ADR Client-Level Data Elements 2017.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	ADAP Grantee Report and Client Level Data Elements 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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	B	B - ADR Grantee Report.docx	B - ADR Grantee Report.docx	Yes	Yes	Fillable Fileable
Instruction			D - Instruction Manual 2016 ADR_11042016_FINAL_508.pdf	Yes	Yes	Fillable Fileable
Form	C	C - ADR Client-Level Data Elements 2017.docx	C - ADR Client-Level Data Elements 2017.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 54	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	54	0	54
Annual IC Time Burden (Hours)	4,698	324	4,374
Annual IC Cost Burden (Dollars)	0	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.