Information Collection

Hospital Campaign Activity Scorecard

IC 209057 under ICR 202008-0915-005 · OMB 0915-0373.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 R Hospital Campaign Activity Scorecard	Form
1 R Scorecard - 2020 Hospital Campaign Scorecard Change Memo 08.03.2020 Scorecard - 2020 Hospital Campaign Scorecard Change Memo REDLINE.pdf	Form
1 C Scorecard - 2020 Hospital Campaign Scorecard Change Memo 08.03.2020 Scorecard - 2020 Hospital Campaign Scorecard Change Memo CLEAN.pdf	Form
0373 Hospital Campaign Change Memo CLEAN.docx 0373 Hospital Campaign Change Memo CLEAN	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

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	1 R	Scorecard - 2020 Hospital Campaign Scorecard Change Memo REDLINE.pdf	08.03.2020 Scorecard - 2020 Hospital Campaign Scorecard Change Memo REDLINE.pdf		Yes	Yes	Fillable Fileable
Form	1 C	Scorecard - 2020 Hospital Campaign Scorecard Change Memo CLEAN.pdf	08.03.2020 Scorecard - 2020 Hospital Campaign Scorecard Change Memo CLEAN.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,500

Number of Respondents for Small Entity: 500

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	1,500	1,500
Annual IC Time Burden (Hours)	375	375
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
0373 Hospital Campaign Change Memo CLEAN	0373 Hospital Campaign Change Memo CLEAN.docx	09/26/2018

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.