Information Collection

Attachment J – Data collection instrument: Site Visit Assessment

IC 227747 under ICR 202009-0935-001 · OMB 0935-0239.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 5 Attachment J – Data collection instrument: Site Visit Assessment	Form and Instruction
5 Site visits Attachment J_Site visit Assessment_Data collection instrument_20170727.docx	Form and Instruction
5 Site visits Attachment J_Site visit Assessment_Data clean.docx	Form and Instruction
Attachment I_Site visit assessment_Cover letter and reminder notice_20170727.docx Attachment I – Site visit assessment_Cover letter and reminder notice.docx	IC Document
Attachment I_Site visit assessment_Cover letter and reminder notice_20170727.docx Attachment I – Site visit assessment_Cover letter and reminder notice.docx	IC Document

IC Title:

Attachment J â Data collection instrument: Site Visit Assessment

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 and Instruction	5	Site visits	Attachment J_Site visit Assessment_Data clean.docx		No		Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 18

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	18	-22	40
Annual IC Time Burden (Hours)	72	-248	320
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment I â Site visit assessment_Cover letter and reminder notice.docx	Attachment I_Site visit assessment_Cover letter and reminder notice_20170727.docx	07/28/2017

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