Information Collection

Form 5A: Services Provided

IC 180776 under ICR 202005-0915-003 · 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⚠️ Notice: This information collection may be referencing outdated material.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 20 Form 5A: Services Provided	Form and Instruction
20 Form 5A - clean.docx Form 5A - clean.docx	Form and Instruction
20E Form 5A - edits.docx Form 5A - edits.docx	Form and Instruction

IC Title:

Form 5A: Services Provided

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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	20	Form 5A - clean.docx	Form 5A - clean.docx		Yes	Yes	Fillable Fileable
Form and Instruction	20E	Form 5A - edits.docx	Form 5A - 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 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	1,058	1,058
Annual IC Time Burden (Hours)	1,058	1,058
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.