Information Collection

Form 4: Community Characteristics

IC 180775 under ICR 202603-0915-004 · OMB 0915-0285.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 19 Form 4 - Clean.docx Form 4: Community Characteristics	Form and Instruction
Form 19E Form 4 - edits.docx Form 4: Community Characteristics	Form and Instruction
19 Form 4 - Clean.docx Form 4 - Clean.docx	Form and Instruction
19E Form 4 - edits.docx Form 4 - edits.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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	19				Yes	Yes	Fillable Fileable
Form and Instruction	19E				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,058

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-1,058	1,058
Annual IC Time Burden (Hours)	-1,058	1,058
Annual IC Cost Burden (Dollars)	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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