Information Collection

Out-of-Network Site Visit Report (Form M-3B)

IC 245577 under ICR 202102-0970-001 · OMB 0970-0564.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0564 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form M-3B Out-of-Network Site Visit Report (Form M-3B)	Form and Instruction
Form M-3B Out-of-Network Site Visit Report 03 - Out-of-Network Site Visit Report (Form M-3B).docx	Form and Instruction
Form M-3B Out-of-Network Site Visit Report 03 - Out-of-Network Site Visit Report (Form M-3B).docx	Form and Instruction

IC Title:

Out-of-Network Site Visit Report (Form M-3B)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

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	Form M-3B	Out-of-Network Site Visit Report	03 - Out-of-Network Site Visit Report (Form M-3B).docx		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 24

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
Annual Number of Responses for this IC	120	120
Annual IC Time Burden (Hours)	120	120
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.