Information Collection

Partnership Survey

IC 244128 under ICR 202010-0906-003 · OMB 0906-0059.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0906-0059 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment B4_Partnership Survey.docx	Other-Survey
Attachment B4_Partnership Survey.docx	Other-Survey

IC Title:

Partnership Survey

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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
Other-Survey			Attachment B4_Partnership Survey.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 290

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	290	290
Annual IC Time Burden (Hours)	73	73
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.