Information Collection

Office of Healthcare Information and Counseling (OHIC) Profiles at ACL

IC 258450 under ICR 202302-0985-001 · OMB 0985-0075.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Office of Healthcare Information and Counseling (OHIC) Profiles at ACL	Form and Instruction
0985New OHICProfilesSupplementalInstructions Ins 3.pdf	Instruction
0985New OHICProfilesSupplementalInstructions Ins 3.pdf	Instruction
MIPPA Sub Recipients Report Template 0985New MIPPASubRecipientsReportTemplate Ins 1.pdf	Form and Instruction
MIPPA Sub Recipients Report Template 0985New MIPPASubRecipientsReportTemplate Ins 1.pdf	Form and Instruction
OHIC Profiles Template 0985New OHICProfilesDataCollectionInstrument Ins 2.pdf	Form and Instruction
OHIC Profiles Template 0985New OHICProfilesDataCollectionInstrument Ins 2.pdf	Form and Instruction
OHIC SMP Sub Recipient Report Template 0985New OHIC SMPSubRecipientsReportTemplate Ins 4.pdf	Form and Instruction
OHIC SMP Sub Recipient Report Template 0985New OHIC SMPSubRecipientsReportTemplate Ins 4.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 45 CFR 1321

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	NA	MIPPA Sub Recipients Report Template	0985New MIPPASubRecipientsReportTemplate Ins 1.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	NA	OHIC Profiles Template	0985New OHICProfilesDataCollectionInstrument Ins 2.pdf	Yes	Yes	Fillable Fileable
Instruction			0985New OHICProfilesSupplementalInstructions Ins 3.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	NA	OHIC SMP Sub Recipient Report Template	0985New OHIC SMPSubRecipientsReportTemplate Ins 4.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 125

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	125	125
Annual IC Time Burden (Hours)	104	104
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.