Information Collection

Structural Assessments – Cohort 4 (baseline)

IC 227701 under ICR 201906-0935-002 · OMB 0935-0238.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form b1. Structural Ass Structural Assessments – Cohort 4 (baseline)	Form and Instruction
b1. Structural Ass Attachment B Structural Assessment for Ambulatory Care S Attachment B Structural Assessment for Ambulatory Care.1.docx	Form and Instruction

IC Title:

Structural Assessments â Cohort 4 (baseline)

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	b1. Structural Assessments â Cohort 4 (baseline)	Attachment B Structural Assessment for Ambulatory Care Setting	Attachment B Structural Assessment for Ambulatory Care.1.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 167

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: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	334	167	167
Annual IC Time Burden (Hours)	67	34	33
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.