Preliminary Application Data Request

ARRA Section 3012 Supporting Statement for State Health Information Exchange Cooperative Agreement Program

Documents and Forms

Document Name Document Type
Form 1 Preliminary Application Data Request Form and Instruction
1 Prelimnary Data Request 3012 Preliminary Application.doc Form and Instruction

Information Collection (IC) Details

IC Title:	Preliminary Application Data Request	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

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	Prelimnary Data Request	3012 Preliminary Application.doc		Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

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

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	300	300
Annual IC Time Burden (Hours)	42,000	42,000
Annual IC Cost Burden (Dollars)	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.