Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Application Cover Letter (initial and reconciliation) Modified 120 40 0 Other-no form - provided by grantee
CFO Cover Letter (Initial and Reconciliation) Modified 120 40 0 Other-no form-provided by grantee
Conversation Record (Resident FTE Assessment) Modified 60 220 0 Form CR
Exhibit 1 (Resident FTE Assessment) Modified 60 20 0 Other-no form-provided by grantee
Exhibit 2 (FTE Resident Assessment) Modified 60 20 0 Other-no form-provided by grantee
Exhibit 2 (Initial and Reconciliation) Modified 120 40 0 Other-no form-provided by grantee
Exhibit 3 (FTE Resident Assessment) Modified 60 20 0 Other-no form-provided by grantee
Exhibit 3 (Initial and Reconciliation) Modified 120 40 0 Other-no form-provided by grantee
Exhibit 4 (FTE Resident Assessment) Modified 60 20 0 Other-no form-provided by grantee
Exhibit 4 (Initial and Reconciliation) Modified 120 40 0 Other-no form-provided by grantee
Exhibit C (Resident FTE Assessment) Modified 120 440 0 Form C
Exhibit E (Fiscal Intermediary Introductory Request Letter) Modified 120 440 0 Other-no form-provided by grantee
Exhibit F (Resident FTE Assessment) Modified 120 440 0 Other-no form-provided by grantee
Exhibit N (Resident FTE Assessment) Modified 120 440 0 Form N
Exhibit O(1) (Resident FTE Assessment) Modified 120 440 0 Form O(1)
Exhibit O(2) (Resident FTE Assessment) Modified 60 1590 0 Form O2
Exhibit P (Resident FTE Assessment) Modified 120 440 0 Form P
Exhibit P(2) (FTE Resident Assessment) Modified 120 440 0 Other-no form-provided by grantee
Exhibit S (Resident FTE Assessment) Modified 120 440 0 Form S
Exhibit T (Resident FTE Assessment) Modified 60 220 0 Other-no form-provided by grantee
Exhibit T(1) (Resident FTE Assessment) Modified 60 220 0 Other-no form-provided by grantee
HRSA 99 (Initial and Reconcilation) Modified 120 40 0 Form 99 I and R
HRSA 99-1 (Initial) Modified 60 1590 0 Form 99-1
HRSA 99-1 (Reconcilliation) Modified 60 390 0 Form 99-1 R
HRSA 99-1 Supplemental (FTE Resident Assessment) Modified 60 220 0 Form 99-1 S
HRSA 99-2 (Initial) Modified 60 680 0 Form 99-2 I
HRSA 99-2 (Reconcilliation) Modified 60 220 0 Form 99-2 R
HRSA 99-4 (Reconciliation) Modified 60 750 0 Form 99-4 R
HRSA 99-5 (Initial and Reconciliation) Modified 120 40 0 Form 99-5 I & R
Total burden requested under this ICR: 2640 9980 0  
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