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Federal forms, ICRs, and supporting documents

Information Collection

Healthcare Facility Assessment (HFA)

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

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Healthcare Facility Assessment (HFA) 0920-0852
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form None Healthcare Facility Assessment (HFA) (modified August 2022) Att_C_HFA._Aug22.docx Yes No Paper Only

Health Public Health Monitoring

 

100 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   50 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 100 0 0 0 0 100
Annual IC Time Burden (Hours) 75 0 0 0 0 75
Annual IC Cost Burden (Dollars) 2,652 0 0 0 0 2,652

Title Document Date Uploaded
Healthcare Facility Assessment (HFA) (August 2022 edits in tracked-changes) Att_C_HFA_tracked_Aug22.docx 08/02/2022
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.