Information Collection

Annual Reporting: Demographic Service Utilization, Clinical Indicators, and Program Locations; Performance Indicators and Systems Outcome Measures

IC 219429 under ICR 202603-0906-002 · OMB 0906-0017.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Demographic, Service Utilization, Select Clinical Indicators, and Program Locations Annual Reporting: Demographic Service Utilization, Clinical Indicators, and Program Locations; Performance Indicators and Systems Outcome Measures	Form and Instruction
Form 1 Demographic, Service Utilization, Select Clinical Indicators, and Program Locations Annual Reporting: Demographic Service Utilization, Clinical Indicators, and Program Locations; Performance Indicators and Systems Outcome Measures	Form and Instruction
Form 2 Performance Indicators and Systems Outcome Measures Annual Reporting: Demographic Service Utilization, Clinical Indicators, and Program Locations; Performance Indicators and Systems Outcome Measures	Form and Instruction
Form 2 Performance Indicators and Systems Outcome Measures Annual Reporting: Demographic Service Utilization, Clinical Indicators, and Program Locations; Performance Indicators and Systems Outcome Measures	Form and Instruction
1 Demographic, Service Utilization, Select Clinical Indica Attachment A_Form 1 Revised.docx	Form and Instruction
1 Demographic, Service Utilization, Select Clinical Indica Attachment A_0906-0017_Form 1_Revised 04162026.docx	Form and Instruction
2 Performance Indicators and Systems Outcome Measures Attachment B_Form 2 Revised.docx	Form and Instruction
2 Performance Indicators and Systems Outcome Measures Attachment B_0906-0017_Form 2 Revised 04162026.docx	Form and Instruction

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 and Instruction	1				Yes	Yes	Fillable Fileable
Form and Instruction	2				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 56

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	56	0	56
Annual IC Time Burden (Hours)	65,576	21,840	43,736
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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