Information Collection

Agreement with Health Care Org

IC 246883 under ICR 202108-0920-009 · OMB 0920-1335.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1335 can be found here:

Documents and Forms

Document Name Document Type
ROCIS - Agreement with HCO and LHA.docx Instruction
ROCIS - Agreement with HCO and LHA.docx Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Agreement with Health Care Org	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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
Instruction			ROCIS - Agreement with HCO and LHA.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 130	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	130	130
Annual IC Time Burden (Hours)	1,300	1,300
Annual IC Cost Burden (Dollars)	109,213	109,213

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.