Information Collection

Adult HCBS Registration Form

IC 236877 under ICR 201907-0935-001 · OMB 0935-0245.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0245 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Adult HCBS Registration Form Form
1 Attachment A: Adult HCBS Registration Form Attachment A Registration Form_FINAL 7-15-19.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Adult HCBS Registration Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	Attachment A: Adult HCBS Registration Form	Attachment A Registration Form_FINAL 7-15-19.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 51	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 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	51	51
Annual IC Time Burden (Hours)	4	4
Annual IC Cost Burden (Dollars)	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.