Information Collection

Healthcare Provider (Profit/Non-Profit Business)

IC 205111 under ICR 201810-0584-001 · OMB 0584-0580.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0584-0580 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
App_F1.72-month HW measurement card - English 10-8-18.docx	Other-Appendix F1 72-month H/W Measu
App_F2.72-month HW measurement card - Spanish 10-8-18.docx	Other-Appendix F2 72-month H/W Measu

IC Title:

Healthcare Provider (Profit/Non-Profit Business)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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
Other-Appendix F1 72-month H/W Measurement Card - English			App_F1.72-month HW measurement card - English 10-8-18.docx		No		Paper Only
Other-Appendix F2 72-month H/W Measurement Card - Spanish			App_F2.72-month HW measurement card - Spanish 10-8-18.docx		No		Paper Only

Line of Business: Income Security

Subfunction: Food and Nutrition Assistance

Privacy Act System of Records

Title: FNS-8 USDA/FNS Studies and Reports

FR Citation: 56 FR 19078

Number of Respondents: 851

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	Previously Approved
Annual Number of Responses for this IC	851	517	334
Annual IC Time Burden (Hours)	142	114	28
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.