Information Collection

SSG Fox SPGP - Intake Form & Assessments

IC 253143 under ICR 202203-2900-009 · OMB 2900-0904.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0904 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 10-317b SSG Fox SPGP - Intake Form & Assessments	Form and Instruction
10-317b SSG Fox SPGP - Intake Form & Assessments SSG Fox SPGP_Intake Form_10-317b_Final.docx	Form and Instruction
10-317b SSG Fox SPGP - Intake Form & Assessments SSG Fox SPGP_Intake Form_10-317b_Final.docx	Form and Instruction

IC Title:

SSG Fox SPGP - Intake Form & Assessments

Agency IC Tracking Number:

2900-NEW

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	10-317b	SSG Fox SPGP - Intake Form & Assessments	SSG Fox SPGP_Intake Form_10-317b_Final.docx		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 90

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	6,030	6,030
Annual IC Time Burden (Hours)	3,015	3,015
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.