View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	Division of Independent Review Objective Review Assessment Survey	Agency IC Tracking Number:

IC Status: Unchanged

Obligation to Respond: Voluntary

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	1.1	Screenshot Reviewer Instr	DIR Review Assessment Survey form 1 - screenshot Reviewer instr.pdf		Yes	Yes	Fillable Fileable
Form	2	Form Chair Q 1-5	FORM CHAIR Q 1-5.pdf		Yes	Yes	Fillable Fileable
Form	1	FORM Reviewer Evaluation Q 1- 15	FORM Reviewer Evaluation Q 1- 15.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	1.2	FORM Reviewer Evaluation-Field Review Q 1 - 12	FORM Reviewer Evaluation-Field Review Q 1 - 12.pdf		Yes	Yes	Fillable Fileable
Other-Public Burden Statement Screenshot			Public Burden Statement Screenshot.pdf		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,300	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	2,300	0	0	0	0	2,300
Annual IC Time Burden (Hours)	575	0	0	0	0	575
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Original Generic Request	Supporting Statement A - DIR Review Assessment Surve.docx	01/09/2024

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.