Information Collection

Assurance of Compliance

IC 238746 under ICR 202302-0945-001 · OMB 0945-0008.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0945-0008 can be found here:

Documents and Forms

Document Name Document Type
Form HHS Form 690 Assurance of Compliance Form and Instruction
HHS Form 690 Assurance of Compliance Revised 690 form.docx www.hhs.gov/civil-rights/for-providers/clearance-medicare-providers/index.html Form and Instruction
HHS Form 690 Assurance of Compliance Revised 690 form.docx www.hhs.gov/civil-rights/for-providers/clearance-medicare-providers/index.html Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Assurance of Compliance	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	HHS Form 690	Assurance of Compliance	Revised 690 form.docx	https://www.hhs.gov/civil-rights/for-providers/clearance-medicare-providers/index.html	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 9,595	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	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	9,595	-500,290	9,595	500,290
Annual IC Time Burden (Hours)	38,380	-2,501,450	38,380	2,501,450
Annual IC Cost Burden (Dollars)	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.