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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.