Information Collection

Client Report

IC 269447 under ICR 202407-0906-003 · OMB 0906-0039.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0906-0039 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 3 Client Report	Form and Instruction
3 Client Report 2024 RSR Client Level Data Elements Instrument (OMB Submission).pdf	Form and Instruction
3 Client Report 2024 RSR Client Level Data Elements Instrument (OMB Submission).pdf	Form and Instruction

IC Title:

Client Report

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	3	Client Report	2024 RSR Client Level Data Elements Instrument (OMB Submission).pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,532

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
Annual Number of Responses for this IC	1,532	1,532
Annual IC Time Burden (Hours)	173,116	173,116
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.