Information Collection

Apllication Waiver/ Supplemental B Clinical Care

IC 46706 under ICR 202307-0990-001 · OMB 0990-0001.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 426 Apllication Waiver/ Supplemental B Clinical Care	Form
Form 426 Application Apllication Waiver/ Supplemental B Clinical Care	Form
Form 426 Application Apllication Waiver/ Supplemental B Clinical Care	Form
426 Application 0990-0001waiver application.doc	Form
426 Application 0990-0001waiver application.doc	Form
426 Application 0990-0001_waiver-supplementary_A info.doc	Form
426 Application 0990-0001_waiver-supplementary_A info.doc	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 45 CFR 50.CFR

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
Form	426				No	No	Paper Only
Form	426				No	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 35

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	35	0	35
Annual IC Time Burden (Hours)	350	0	350
Annual IC Cost Burden (Dollars)	0	-43,750	43,750

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.

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