Information Collection

Program Specific Form

IC 256153 under ICR 202508-0906-003 · OMB unassigned.

Documents and Forms

Document Name Document Type
Form 1 Program Specific Form Program Specific Form Form
1 Program Specific Form BHW Program Specific Form.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Program Specific Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	Program Specific Form	BHW Program Specific Form.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,069	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-2,069	2,069
Annual IC Time Burden (Hours)	-28,966	28,966
Annual IC Cost Burden (Dollars)	0	0

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.

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