Information Collection

Dental Assessment Form - Reporting Time

IC 217789 under ICR 202308-0970-002 · OMB 0970-0466.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0466 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Dental Assessment Form - Reporting Time	Form
1 Dental Assessment Form ORR Dental Assessment Form.docx	Form
1 Dental Assessment Form ORR Dental Assessment Form.docx	Form
Attachment C_Dental Assessment Form Instructional Letter for Dental Providers.docx Attachment C - Dental Assessment Form Instructional Letter for Dental Providers	IC Document
Attachment C_Dental Assessment Form Instructional Letter for Dental Providers.docx Attachment C - Dental Assessment Form Instructional Letter for Dental Providers	IC Document

IC Title:

Dental Assessment Form - Reporting Time

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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
Form	1	Dental Assessment Form	ORR Dental Assessment Form.docx		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title: ORR Division of Children's Services Records

FR Citation: 81 FR 46682

Number of Respondents: 250

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	16,000	7,030	8,970
Annual IC Time Burden (Hours)	1,920	-323	2,243
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment C - Dental Assessment Form Instructional Letter for Dental Providers	Attachment C_Dental Assessment Form Instructional Letter for Dental Providers.docx	08/02/2023

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.