Information Collection

Health Center Component Facility Interview (Survey year: 2025 & 2027)

IC 247676 under ICR 202412-0920-002 · OMB 0920-0234.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0234 Health Center Component Facility Interview (Survey year: 2025 & 2027)	Form and Instruction
Form 0920-0234 2025-2027 Health Center Component Facility Interview Health Center Component Facility Interview (Survey year: 2025 & 2027)	Form and Instruction
0920-0234 2025-2027 Health Center Component Facility Interview Attachment C2_2025-2027 Health Center Facility Interview.docx	Form and Instruction
0920-0234 2025-2027 Health Center Component Facility Interview Attachment C2_2025-2027 Health Center Facility Interview.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

0920-0234

Is this a Common Form? Yes

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	0920-0234				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 221

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: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	221	148	73
Annual IC Time Burden (Hours)	166	111	55
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.

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