Information Collection

Program Specific Form

IC 256153 under ICR 202209-0906-002 · OMB 0906-0073.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0906-0073 can be found here:

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

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.