Information Collection

Form 5A: Services Provided

IC 180776 under ICR 202603-0915-004 · OMB 0915-0285.

Documents and Forms

Document Name Document Type
Form 14 2026 Form 5A: Services Provided Form 5A: Services Provided Form and Instruction
14 2026 Form 5A: Services Provided 2026 14a. Form 5A Services Provided.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Form 5A: Services Provided	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 and Instruction	14	2026 Form 5A: Services Provided	2026 14a. Form 5A Services Provided.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,428	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,428	370	1,058
Annual IC Time Burden (Hours)	357	-701	1,058
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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