Information Collection

HRSA Ryan White HIV/AIDS Program (RWHAP) Core Medical Services Waiver Request Attestation Form

IC 248963 under ICR 202406-0906-003 · OMB 0906-0065.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 HRSA Ryan White HIV/AIDS Program (RWHAP) Core Medical Services Waiver Request Attestation Form	Form and Instruction
1 RWHAP Core Medical Services Waiver Attestation Form FINAL RWHAP Core Medical Services Waiver Attestation Form_06252024.docx	Form and Instruction
1 RWHAP Core Medical Services Waiver Attestation Form FINAL RWHAP Core Medical Services Waiver Attestation Form_06252024.docx	Form and Instruction

IC Title:

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 and Instruction	1	RWHAP Core Medical Services Waiver Attestation Form	FINAL RWHAP Core Medical Services Waiver Attestation Form_06252024.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 23

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	Previously Approved
Annual Number of Responses for this IC	23	1	22
Annual IC Time Burden (Hours)	11	-77	88
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.