Information Collection

Ryan White Services Report Service Provider Report

IC 233866 under ICR 202111-0906-001 · OMB 0906-0039.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0906-0039 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2 Ryan White Services Report Service Provider Report	Form
2 2018_Service_Provider_Form_Screenshots C - 2018_Service_Provider_Form_Screenshots_4242018_updated_final_RSR Instrument.docx	Form
2 2018_Service_Provider_Form_Screenshots C - 2018_Service_Provider_Form_Screenshots_4242018_updated_final_RSR Instrument.docx	Form

IC Title:

Ryan White Services Report Service Provider Report

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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	2	2018_Service_Provider_Form_Screenshots	C - 2018_Service_Provider_Form_Screenshots_4242018_updated_final_RSR Instrument.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,079

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
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-2,079	2,079
Annual IC Time Burden (Hours)	-27,027	27,027
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.