Grantee Data Collection Form

Frontier Community Healthcare Network Coordination Grant

Documents and Forms

Document Name Document Type
Form 8 Grantee Data Collection Form Form and Instruction
8 Grantee Data Collection Form GranteeDataCollection_OMBClearancePackage_10032013.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Grantee Data Collection Form	Agency IC Tracking Number:

Is this a Common Form? No		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	8	Grantee Data Collection Form	GranteeDataCollection_OMBClearancePackage_10032013.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 11	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	44	44
Annual IC Time Burden (Hours)	176	176
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.