Information Collection

Health Center Organizational Assessment

IC 222374 under ICR 201912-0920-012 · OMB 0920-1156.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1156 Health Center Organizational Assessment	Form and Instruction
0920-1156 Health Center Org Assessment Att 3a Health Center Organizational Assessment 6_22_2016 final.docx	Form and Instruction
0920-1156 Health Center Org Assessment Online Att 3b Health Center Organizational Assessment Online Version.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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	0920-1156	Health Center Org Assessment	Att 3a Health Center Organizational Assessment 6_22_2016 final.docx		Yes	Yes	Fillable Fileable
Form and Instruction	0920-1156	Health Center Org Assessment Online	Att 3b Health Center Organizational Assessment Online Version.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	4	4
Annual IC Time Burden (Hours)	8	8
Annual IC Cost Burden (Dollars)	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.