Information Collection

Service Provider Feedback Form

IC 201612 under ICR 202206-0930-002 · OMB 0930-0270.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0270 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Service Provider F Service Provider Feedback Form	Form and Instruction
Service Provider F Service Provider Feedback Form -Att-G-ServiceProviderFeedback-508-OMB2022_2021-11-03 _ clean.pdf	Form and Instruction
Service Provider F Service Provider Feedback Form -Att-G-ServiceProviderFeedback-508-OMB2022_2021-11-03 _ clean.pdf	Form and Instruction

IC Title:

Service Provider Feedback Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	Service Provider Feedback Form	Service Provider Feedback Form	-Att-G-ServiceProviderFeedback-508-OMB2022_2021-11-03 _ clean.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Service Provider Feedback Form

FR Citation: 75 FR 28264

Number of Respondents: 750

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
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	750	650	100
Annual IC Time Burden (Hours)	308	267	41
Annual IC Cost Burden (Dollars)	0	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.