Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Application Cover Letter Unchanged 120 40 0 Instruction
CFO Cover Letter Unchanged 120 40 0 Instruction
Conversation Record (Resident FTE Assessment) Unchanged 30 110 0 Form Conversation Record (Resident FTE Assessment) Conversation Record (Resident FTE Assessment)
Exhibit 1 (Resident FTE Assessment) Unchanged 30 10 0 Instruction
Exhibit 2 (Initial, Resident FTE Assessment, Reconciliation) Unchanged 90 30 0 Instruction
Exhibit 3 (Initial, Resident FTE Assessment, Reconciliation) Unchanged 90 30 0 Instruction
Exhibit 4 (Initial, Resident FTE Assessment, Reconciliation) Unchanged 90 30 0 Instruction
Exhibit C (Resident FTE Assessment) Unchanged 30 110 0 Form Exhibit C (Resident FTE Assessment) Exhibit C (Resident FTE Assessment)
Exhibit F (Resident FTE Assessment) Unchanged 30 110 0 Instruction
Exhibit N (Resident FTE Assessment) Unchanged 30 110 0 Form Exhibit N (Resident FTE Assessment) Exhibit N (Resident FTE Assessment)
Exhibit O(1) (Resident FTE Assessment) Unchanged 30 110 0 Form Exhibit O(1) (Resident FTE Assessment) Exhibit O(1) (Resident FTE Assessment)
Exhibit O(2) (Resident FTE Assessment) Unchanged 30 795 0 Form Exhibit O(2) (Resident FTE Assessment) Exhibit O(2) (Resident FTE Assessment)
Exhibit P (Resident FTE Assessment) Unchanged 30 110 0 Form Exhibit P (Resident FTE Assessment) Exhibit P (Resident FTE Assessment)
Exhibit P(2) (Resident FTE Assessment) Unchanged 30 110 0 Instruction
Exhibit S (Resident FTE Assessment) Unchanged 30 110 0 Form Exhibit S (Resident FTE Assessment) Exhibit S (Resident FTE Assessment)
Exhibit T (Resident FTE Assessment) Unchanged 30 110 0 Instruction
Exhibit T(1) (Resident FTE Assessment) Unchanged 30 110 0 Instruction
FTE Assessment Letter (Resident FTE Assessment) Unchanged 30 10 0 Instruction
HRSA 99 Unchanged 120 40 0 Form 99 HRSA 99
HRSA 99-1 Modified 60 1590 0 Form 1 HRSA 99-1 (Initial)
HRSA 99-1 Reconcilliation New 60 390 0 Form 1 HRSA 99-1 (Reconciliation)
HRSA 99-1 Supplemental (FTE Resident Assessment) New 60 220 0 Form 1 HRSA 99-1 (Supplemental FTE Resident Assessment)
HRSA 99-2 Unchanged 120 900 0 Form HRSA 99-2 HRSA 99-2
HRSA 99-4 Unchanged 60 750 0 Form HRSA 99-4 HRSA 99-4
HRSA 99-5 (Initial and Reconciliation) Modified 120 186 0 Form 1 HRSA 99-5 (Initial and Reconciliation).docx
Total burden requested under this ICR: 1500 6161 0  
To view an IC, click on IC Title