Program Application

[NCCDPHP] Million Hearts® Hospital/Health System Recognition Program

Documents and Forms

Document Name Document Type
Form 0920-1274 Program Application Form
0920-1274 Data Collection Application Attachment 2a. Currently Approved Data Collection Tool 1_Application_0920-1274.docx Form

Information Collection (IC) Details

IC Title:	Program Application	Agency IC Tracking Number:	0920-1274

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	0920-1274	Data Collection Application	Attachment 2a. Currently Approved Data Collection Tool 1_Application_0920-1274.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	50	0	50
Annual IC Time Burden (Hours)	134	1	133
Annual IC Cost Burden (Dollars)	0	-7,158	7,158

Documents for IC

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.