Information Collection

Federally Qualified Health Center Cost Report Form

IC 217774 under ICR 202412-0938-013 · OMB 0938-1298.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 224-14 Federally Qualified Health Center Cost Report Form	Form
Form 224-14 Federally Qualified Health Center Cost Report Federally Qualified Health Center Cost Report Form	Form
R7P244i.pdf	Instruction
R7P244i.pdf	Instruction
224-14 Federally Qualified Health Center Cost Report R7P244f.pdf	Form
224-14 Federally Qualified Health Center Cost Report R7P244f.pdf	Form

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: 42 CFR 413.20 42 CFR 413.24

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	224-14				Yes	Yes	Fillable Fileable
Instruction					Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,967

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	2,967	77	2,890
Annual IC Time Burden (Hours)	172,086	4,466	167,620
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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