Information Collection

Financial Performance Measures

IC 193520 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⚠️ Notice: This information collection may be referencing outdated material.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 12 Financial Performance Measures	Form and Instruction
12 Financial Performance Measures - clean.docx Financial Performance Measures - clean.docx	Form and Instruction
12E Financial Performance Measures - edits.docx Financial Performance Measures - edits.docx	Form and Instruction

IC Title:

Financial Performance Measures

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	12	Financial Performance Measures - clean.docx	Financial Performance Measures - clean.docx		Yes	Yes	Fillable Fileable
Form and Instruction	12E	Financial Performance Measures - edits.docx	Financial Performance Measures - 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)	1,587	1,587
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.