Information Collection

Healthcare Facility Assessment (HFA)

IC 192451 under ICR 202207-0920-011 · OMB 0920-0852.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Healthcare Facility Assessment (HFA)	Form
Healthcare Facility Assessment (HFA) (modified August 2022) Healthcare Facility Assessment (HFA)	Form
Healthcare Facility Assessment (HFA) (modified August 20 Att_C_HFA._Aug22.docx	Form
Healthcare Facility Assessment (HFA) (modified August 20 Att_C_HFA._Aug22.docx	Form
Att_C_HFA_tracked_Aug22.docx Healthcare Facility Assessment (HFA) (August 2022 edits in tracked-changes)	IC Document
Att_C_HFA_tracked_Aug22.docx Healthcare Facility Assessment (HFA) (August 2022 edits in tracked-changes)	IC Document

IC Title:

Agency IC Tracking Number:

0920-0852

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	None				Yes	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

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: 50 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	75	75
Annual IC Cost Burden (Dollars)	2,652	2,652

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Healthcare Facility Assessment (HFA) (August 2022 edits in tracked-changes)		08/02/2022

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

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].