Information Collection

Hospital Campaign Activity Scorecard

IC 209057 under ICR 201905-0915-003 · OMB 0915-0373.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0373 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Hospital Campaign Activity Scorecard	Form and Instruction
1 HC Scorecard 2020.docx FORM - Scorecard - OMB Package HC Scorecard 2020.docx	Form and Instruction
0373 Hospital Campaign Change Memo CLEAN.docx 0373 Hospital Campaign Change Memo CLEAN	IC Document

IC Title:

Hospital Campaign Activity Scorecard

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
Form and Instruction	1	HC Scorecard 2020.docx	FORM - Scorecard - OMB Package HC Scorecard 2020.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,500

Number of Respondents for Small Entity: 500

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,500	250	1,250
Annual IC Time Burden (Hours)	375	-84	459
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
0373 Hospital Campaign Change Memo CLEAN	0373 Hospital Campaign Change Memo CLEAN.docx	09/26/2018

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