Information Collection

Rural Health Opioid Program

IC 231350 under ICR 201810-0906-004 · OMB 0906-0037.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Rural Health Opioid Program	Form
1 RHOP draft PIMS.docx RHOP draft PIMS.docx	Form
0906-0037 RHOP OMB Number and Expiration.jpg 0906-0037 RHOP OMB Number and Expiration	IC Document
0906-0037 RHOP Burden Statement.jpg 0906-0037 RHOP Burden Statement	IC Document

IC Title:

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	RHOP draft PIMS.docx	RHOP draft PIMS.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

Number of Respondents for Small Entity: 10

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	10	10
Annual IC Time Burden (Hours)	110	110
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
0906-0037 RHOP OMB Number and Expiration	0906-0037 RHOP OMB Number and Expiration.jpg	10/24/2018
0906-0037 RHOP Burden Statement	0906-0037 RHOP Burden Statement.jpg	10/24/2018

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