Information Collection

Health Center Attestation

IC 245412 under ICR 202310-0915-003 · OMB 0915-0126.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 41 Health Center Attestation	Form and Instruction
41 Health Center Attestation.pdf Health Center Attestation.pdf	Form and Instruction
41 Health Center Attestation.pdf Health Center Attestation.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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
Form and Instruction	41	Health Center Attestation.pdf	Health Center Attestation.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title: System of Record Notice 09-15-0054

FR Citation: 88 FR 17854

Number of Respondents: 724

Number of Respondents for Small Entity: 100

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	Previously Approved
Annual Number of Responses for this IC	724	2	722
Annual IC Time Burden (Hours)	724	2	722
Annual IC Cost Burden (Dollars)	0	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.