Information Collection

Small Rural Hospital Improvement Program COVID-19 Testing and Mitigation Reporting Portal

IC 249666 under ICR 202205-0906-001 · OMB 0906-0066.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0906-0066 Small Rural Hospital Improvement Program COVID-19 Testing and Mitigation Reporting Portal	Form and Instruction
0906-0066 HRSA FORHP COVID-19 Data Report 6. FORM - HRSA FORHP COVID-19 Data Report.docx	Form and Instruction
0906-0066 HRSA FORHP COVID-19 Data Report 6. FORM - HRSA FORHP COVID-19 Data Report.docx	Form and Instruction
5. Supporting Statement A - SHIP COVID Testing Mitigation Program 03.02.2022.docx Supporting Statement A - SHIP COVID Testing Mitigation Program	IC Document
5. Supporting Statement A - SHIP COVID Testing Mitigation Program 03.02.2022.docx Supporting Statement A - SHIP COVID Testing Mitigation Program	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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 and Instruction	0906-0066	HRSA FORHP COVID-19 Data Report	6. FORM - HRSA FORHP COVID-19 Data Report.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,540

Number of Respondents for Small Entity: 1,540

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	9,240	9,240
Annual IC Time Burden (Hours)	2,310	2,310
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement A - SHIP COVID Testing Mitigation Program	5. Supporting Statement A - SHIP COVID Testing Mitigation Program 03.02.2022.docx	05/03/2022

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.