Information Collection

Program Participation

IC 237364 under ICR 201908-0937-001 · OMB 0937-0209.

Documents and Forms

Document Name Document Type
YES Data Collection Form.xlsx Other-Recording sheet
YES Program Level Performance measures instructions.docx YES Program Level Performance measures instructions IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Program Participation	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
Other-Recording sheet			YES Data Collection Form.xlsx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 14	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 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	28	28
Annual IC Time Burden (Hours)	117	117
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
YES Program Level Performance measures instructions	YES Program Level Performance measures instructions.docx	08/14/2019

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