Information Collection

COVID-19 Provider Relief Fund (PRF) Reporting Activities

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	COVID-19 Provider Relief Fund (PRF) Reporting Activities	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
Form	1	Data Form Elements	PRF Reporting Activities - 4 Data Form Elements - revised 12-9.xlsx		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 %

	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

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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