Information Collection

Gap Analysis

IC 248491 under ICR 202107-0935-003 · OMB 0935-0260.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0260 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 3 Gap Analysis	Form and Instruction
3 Attachment B: ICU/Non-ICU Gap Analysis Att B ICU-Non-ICU Gap Analysis.docx	Form and Instruction
3 Attachment B: ICU/Non-ICU Gap Analysis Att B ICU-Non-ICU Gap Analysis.docx	Form and Instruction
4 Attachment C: Surgical Services Gap Analysis Att C Surgical Services Gap Analysis.docx	Form and Instruction
4 Attachment C: Surgical Services Gap Analysis Att C Surgical Services Gap Analysis.docx	Form and Instruction
5 Attachment D: LTC Gap Analysis Att D LTC Gap Analysis.docx	Form and Instruction
5 Attachment D: LTC Gap Analysis Att D LTC Gap Analysis.docx	Form and Instruction

IC Title:

Gap Analysis

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	3	Attachment B: ICU/Non-ICU Gap Analysis	Att B ICU-Non-ICU Gap Analysis.docx	Yes	Yes	Fillable Fileable
Form and Instruction	4	Attachment C: Surgical Services Gap Analysis	Att C Surgical Services Gap Analysis.docx	Yes	Yes	Fillable Fileable
Form and Instruction	5	Attachment D: LTC Gap Analysis	Att D LTC Gap Analysis.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 467

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	934	934
Annual IC Time Burden (Hours)	934	934
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.