Information Collection

NHHCIA NCC Income Analysis Form

IC 258270 under ICR 202603-0915-004 · OMB 0915-0285.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 30 2026 NHHCIA NCC Income Analysis Form NHHCIA NCC Income Analysis Form	Form and Instruction
30 2026 NHHCIA NCC Income Analysis Form 2026 30. NHHCIA NCC Income Analysis Form.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	30				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5

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
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	5	-13	18
Annual IC Time Burden (Hours)	1	-2	3
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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