Information Collection

Instrument 4 - Provider photo journals

IC 260159 under ICR 202305-0970-008 · OMB 0970-0612.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0612 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Instrument 4. Provider photo journals_30day.docx	Other-photo journals
Instrument 4. Provider photo journals_30day.docx	Other-photo journals
Instrument 4. Provider photo journals_Spanish_30day.docx	Other-photo journals - Spanish
Instrument 4. Provider photo journals_Spanish_30day.docx	Other-photo journals - Spanish

IC Title:

Instrument 4 - Provider photo journals

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

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
Other-photo journals			Instrument 4. Provider photo journals_30day.docx		Yes	Yes	Fillable Fileable
Other-photo journals - Spanish			Instrument 4. Provider photo journals_Spanish_30day.docx		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social 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: Not-for-profit institutions, 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	480	480
Annual IC Time Burden (Hours)	48	48
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.