Information Collection

Checklist for Adding a new Service Delivery Site

IC 193525 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⚠️ Notice: This information collection may be referencing outdated material.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 3 Checklist for Adding a new Service Delivery Site	Form and Instruction
3 Checklist for Adding a New Service Delivery Site - Clean Checklist for Adding a New Service Delivery Site - Clean.docx	Form and Instruction
3E Checklist for Adding a New Service Delivery Site edits.d Checklist for Adding a New Service Delivery Site edits.docx	Form and Instruction

IC Title:

Checklist for Adding a new Service Delivery Site

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	3	Checklist for Adding a New Service Delivery Site - Clean.docx	Checklist for Adding a New Service Delivery Site - Clean.docx		Yes	Yes	Fillable Fileable
Form and Instruction	3E	Checklist for Adding a New Service Delivery Site edits.docx	Checklist for Adding a New Service Delivery Site 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: 1,480

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	1,480	1,480
Annual IC Time Burden (Hours)	2,960	2,960
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.