Information Collection

HC Facility Interview (2021-2023)

IC 247676 under ICR 202105-0920-006 · OMB 0920-0234.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0234 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-0234 HC Facility Interview (2021-2023) Form and Instruction
0920-0234 CHC Facility Interview Questionnaire Att F2- 2021 Draft CHC Facility Interview Questionnaire.docx Form and Instruction
0920-0234 CHC Facility Interview Questionnaire Att F2- 2021 Draft CHC Facility Interview Questionnaire.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	HC Facility Interview (2021-2023)	Agency IC Tracking Number:	0920-0234

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-0234	CHC Facility Interview Questionnaire	Att F2- 2021 Draft CHC Facility Interview Questionnaire.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 92	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 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	92	92
Annual IC Time Burden (Hours)	69	69
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.