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HRSA 99-5 (Initial and Reconciliation)
Children's Hospital Graduate Medical Education Program
OMB: 0915-0247
IC ID: 211220
OMB.report
HHS/HSA
OMB 0915-0247
ICR 202210-0915-007
IC 211220
( )
Documents and Forms
Document Name
Document Type
Form 99-5 I & R
HRSA 99-5 (Initial and Reconciliation)
Form
99-5 I & R HRSA 99-5 (Initial and Reconciliation)
HRSA 99-5 (Initial and Reconciliation).docx
Form
99-5 I & R HRSA 99-5 (Initial and Reconciliation)
HRSA 99-5 (Initial and Reconciliation).docx
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
HRSA 99-5 (Initial and Reconciliation)
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
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
99-5 I & R
HRSA 99-5 (Initial and Reconciliation)
HRSA 99-5 (Initial and Reconciliation).docx
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
60
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:
100 %
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
120
0
0
0
0
120
Annual IC Time Burden (Hours)
40
0
0
0
0
40
Annual IC Cost Burden (Dollars)
0
0
0
0
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.
