Information Collection

Form 4: Community Characteristics

IC 180775 under ICR 202001-0915-001 · OMB 0915-0285.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0285 can be found here:

Documents and Forms

Document Name Document Type
Form 19 Form 4: Community Characteristics Form and Instruction
19 Form 4 - Clean.docx Form 4 - Clean.docx Form and Instruction
19E Form 4 - edits.docx Form 4 - edits.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Form 4: Community Characteristics	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	19	Form 4 - Clean.docx	Form 4 - Clean.docx		Yes	Yes	Fillable Fileable
Form and Instruction	19E	Form 4 - edits.docx	Form 4 - edits.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,058	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,058	58	1,000
Annual IC Time Burden (Hours)	1,058	58	1,000
Annual IC Cost Burden (Dollars)	0	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.