Please provide the following information. The information you provide for data submission purposes will be kept confidential.
Program Information Form:
Program Identification Number
Associated Agency Identification Number
Program Name
Address1
Address2
City
State
Zip
Program Contact Name
Program Contact Email
Program Contact Phone
Program Setting Type (e.g. Provider-Owned, Individual Residence, etc.)
Population(s) Served (e.g. TBI/Physically Disabled, etc.)
Total Number of Enrollees
Program Funding Sources (e.g. Medicaid/Non-Medicaid, Managed Long-Term Services and Supports)
Public reporting burden for this collection of information is estimated to average 5 minutes per response, the estimated time required to complete the form. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-xxxx) AHRQ, 5600 Fishers Lane, Rockville, MD 20857. |
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Michael Corrothers |
| File Modified | 0000-00-00 |
| File Created | 2023-08-26 |