Information Collection

Office of Community Care – IVC Survey Collection

IC 273946 under ICR 202503-2900-010 · OMB 2900-0876.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0876 can be found here:

2025-11-26 - Revision of a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2900-0876 Office of Community Care – IVC Survey Collection	Form and Instruction
Form 2900-0876 Attending Wireframe Office of Community Care – IVC Survey Collection	Form and Instruction
Form 2900-0876 Billing Wireframe Office of Community Care – IVC Survey Collection	Form and Instruction
Form 2900-0876 Choosing Wireframe Office of Community Care – IVC Survey Collection	Form and Instruction
Form 2900-0876 Emergency Wireframe Office of Community Care – IVC Survey Collection	Form and Instruction
Form 2900-0876 RX Wireframe Office of Community Care – IVC Survey Collection	Form and Instruction
Form 2900-0876 Scheduling Wireframe Office of Community Care – IVC Survey Collection	Form and Instruction
2900-0876 Attending Wireframe Attending Community Care Wireframe 20250129.docx	Form and Instruction
2900-0876 Attending Wireframe Attending Community Care Wireframe 20250129.docx	Form and Instruction
2900-0876 Billing Wireframe Billing Community Care Wireframe 20250129.docx	Form and Instruction
2900-0876 Billing Wireframe Billing Community Care Wireframe 20250129.docx	Form and Instruction
2900-0876 Choosing Wireframe Choosing Community Care Wireframe 20250129.docx	Form and Instruction
2900-0876 Choosing Wireframe Choosing Community Care Wireframe 20250129.docx	Form and Instruction
2900-0876 Emergency Wireframe Emergency Community Care Wireframe 20250129.docx	Form and Instruction
2900-0876 Emergency Wireframe Emergency Community Care Wireframe 20250129.docx	Form and Instruction
2900-0876 RX Wireframe Prescription Community Care Wireframe 20250129.docx	Form and Instruction
2900-0876 RX Wireframe Prescription Community Care Wireframe 20250129.docx	Form and Instruction
2900-0876 Scheduling Wireframe Scheduling Community Care Wireframe 20250129.docx	Form and Instruction
2900-0876 Scheduling Wireframe Scheduling Community Care Wireframe 20250129.docx	Form and Instruction
A11 Fast-Track Clarance Request Template_OCC_IVC_Surveys.docx A-11 Template IVC Surveys	IC Document
A11 Fast-Track Clarance Request Template_OCC_IVC_Surveys.docx A-11 Template IVC Surveys	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Office of Community Care â IVC Survey Collection

Agency IC Tracking Number:

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	2900-0876	Yes	Yes	Fillable Fileable
Form and Instruction	2900-0876	Yes	Yes	Fillable Fileable
Form and Instruction	2900-0876	Yes	Yes	Fillable Fileable
Form and Instruction	2900-0876	Yes	Yes	Fillable Fileable
Form and Instruction	2900-0876	Yes	Yes	Fillable Fileable
Form and Instruction	2900-0876	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 65,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	65,000	65,000
Annual IC Time Burden (Hours)	4,875	4,875
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
A-11 Template IVC Surveys		02/27/2025

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

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