View Information Collection (IC)

View Information Collection (IC)

IC Title:	Office of Healthcare Information and Counseling (OHIC) Profiles at ACL	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 45 CFR 1321

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	NA	MIPPA Sub Recipients Report Template	0985New MIPPASubRecipientsReportTemplate Ins 1.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	NA	OHIC Profiles Template	0985New OHICProfilesDataCollectionInstrument Ins 2.pdf		Yes	Yes	Fillable Fileable
Instruction			0985New OHICProfilesSupplementalInstructions Ins 3.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	NA	OHIC SMP Sub Recipient Report Template	0985New OHIC SMPSubRecipientsReportTemplate Ins 4.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: 125	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	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	125	0	125	0	0	0
Annual IC Time Burden (Hours)	104	0	104	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	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.