Information Collection

Form 3A: FQHC Look-Alike Budget Information

IC 239173 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form 18 Form 3A: FQHC Look-Alike Budget Information	Form and Instruction
18 Form 3A - clean.docx Form 3A - clean.docx	Form and Instruction
18E Form 3A - edits.docx Form 3A - edits.docx	Form and Instruction

IC Title:

Form 3A: FQHC Look-Alike Budget Information

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	18	Form 3A - clean.docx	Form 3A - clean.docx		Yes	Yes	Fillable Fileable
Form and Instruction	18E	Form 3A - edits.docx	Form 3A - 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: 50

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	50	50
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.