Program Specific Form

Bureau of Health Workforce (BHW) Program Specific Form

Documents and Forms

Document Name Document Type
Form 1 Program Specific Form Form
1 Program Specific Form BHW Program Specific Form.pdf Form
1 Program Specific Form BHW Program Specific Form.pdf Form

Information Collection (IC) Details

IC Title:	Program Specific Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	Program Specific Form	BHW Program Specific Form.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,069	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,069	2,069
Annual IC Time Burden (Hours)	28,966	28,966
Annual IC Cost Burden (Dollars)	0	0

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.