Information Collection

COVID-19 Provider Relief Fund (PRF) Reporting Activities

IC 250697 under ICR 202601-0906-002 · OMB 0906-0068.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 COVID-19 Provider Relief Fund (PRF) Reporting Activities	Form
Form 1 Data Form Elements COVID-19 Provider Relief Fund (PRF) Reporting Activities	Form
1 Data Form Elements PRF Reporting Activities - 4 Data Form Elements - revised 12-9.xlsx	Form
1 Data Form Elements PRF Reporting Activities - 4 Data Form Elements - revised 12-9.xlsx	Form

IC Title:

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

Number of Respondents for Small Entity: 100

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	100	-307,929	308,029
Annual IC Time Burden (Hours)	629	-1,555,583	1,556,212
Annual IC Cost Burden (Dollars)	0	0	0

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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