Information Collection

Program Application

IC 237207 under ICR 202507-0920-019 · OMB 0920-1274.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1274 Program Application	Form
Form 0920-1274 Data Collection Application Program Application	Form
0920-1274 Data Collection Application Attachment 2a. Currently Approved Data Collection Tool 1_Application_0920-1274.docx	Form
0920-1274 Data Collection Application Attachment 2a. Currently Approved Data Collection Tool 1_Application_0920-1274.docx	Form

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	0920-1274				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 %

table that charts list of burden
	Approved	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

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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