Information Collection

Program Information Form

IC 237058 under ICR 202602-0935-001 · OMB 0935-0245.

Documents and Forms

Document Name Document Type
Form 2 Program Information Form Program Information Form Form and Instruction
2 Program Information Form Attachment D Program Information Form_FINAL_7-15-19.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Program Information Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	2	Program Information Form	Attachment D Program Information Form_FINAL_7-15-19.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 51	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	51	0	51
Annual IC Time Burden (Hours)	4	0	4
Annual IC Cost Burden (Dollars)	563	563	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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