Information Collection

Summative Report (431.424(c)(2)(v))

IC 250574 under ICR 202501-0938-015 · OMB 0938-1162.

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Documents and Forms

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Information Collection (IC) Details

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IC Title:	Summative Report (431.424(c)(2)(v))	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 431.424(c)(2)(v)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 24	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	24	24
Annual IC Time Burden (Hours)	3,840	3,840
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.