Information Collection

Program Participation

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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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
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 %

table that charts list of burden
	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

table that charts IC Documents
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.