Information Collection

HRSA Ryan White HIV/AIDS Program (RWHAP) Core Medical Services Waiver Request Attestation Form

IC 248963 under ICR 202108-0906-002 · OMB 0906-0065.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0906-0065 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 HRSA Ryan White HIV/AIDS Program (RWHAP) Core Medical Services Waiver Request Attestation Form	Form
1 HRSA RWHAP Core Medical Services Waiver Request Attestat FORM - HRSA RWHAP Core Medical Services Waiver Request Attestation.pdf	Form
1 HRSA RWHAP Core Medical Services Waiver Request Attestat FORM - HRSA RWHAP Core Medical Services Waiver Request Attestation.pdf	Form

IC Title:

HRSA Ryan White HIV/AIDS Program (RWHAP) Core Medical Services Waiver Request Attestation Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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	1	HRSA RWHAP Core Medical Services Waiver Request Attestation.pdf	FORM - HRSA RWHAP Core Medical Services Waiver Request Attestation.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 22

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	22	22
Annual IC Time Burden (Hours)	88	88
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.