Program Application

Million Hearts® Hospital/Health System Recognition Program

Documents and Forms

Document Name Document Type
Program Application Form
Million Hearts® Hospital/Health System Recognition Progr 19TG Att 2a. Data Collection Tool Final.docx Form
Million Hearts® Hospital/Health System Recognition Progr 19TG Att 2a. Data Collection Tool Final.docx Form
0920-1274 Million Hearts® Hospitals & Health Systems Recognition P 1274 Att 2b Updated Data Coll Tool.docx Form
0920-1274 Million Hearts® Hospitals & Health Systems Recognition P 1274 Att 2b Updated Data Coll Tool.docx Form

Information Collection (IC) Details

IC Title:	Program Application	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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
Form	none	Million Hearts® Hospital/Health System Recognition Program Application	19TG Att 2a. Data Collection Tool Final.docx		Yes	Yes	Fillable Fileable
Form	0920-1274	Million Hearts® Hospitals & Health Systems Recognition Program Application JUL2022	1274 Att 2b Updated Data Coll Tool.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	50	-50	100
Annual IC Time Burden (Hours)	133	-134	267
Annual IC Cost Burden (Dollars)	7,158	-7,159	14,317

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.