Information Collection

Exhibit E (Fiscal Intermediary Introductory Request Letter)

IC 256635 under ICR 202509-0915-004 · OMB 0915-0247.

Documents and Forms

Document Name Document Type
Exhibit E (FTE Resident Assessment) - Documentation.docx Other-no form-provided by grantee
Exhibit E (FTE Resident Assessment) - Documentation.docx Other-no form-provided by grantee

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Exhibit E (Fiscal Intermediary Introductory Request Letter)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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
Other-no form-provided by grantee			Exhibit E (FTE Resident Assessment) - Documentation.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Graduate Medical Education (GME) Full-Time Equivalent (FTE) Resident Assessment Records â 09-15-0070 (CLEARANCE IN PROCESS)	FR Citation: 1 FR 1

Number of Respondents: 30	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	120	120
Annual IC Time Burden (Hours)	440	440
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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