Form 5A: Services Provided

The Health Center Program Application Forms

OMB: 0915-0285

IC ID: 180776

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

Form 5A: Services Provided
 
No Modified
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 20 Form 5A - clean.docx Form 5A - clean.docx Yes Yes Fillable Fileable
Form and Instruction 20E Form 5A - edits.docx Form 5A - edits.docx Yes Yes Fillable Fileable

Health Health Care Services

 

1,058 0
   
Private Sector Not-for-profit institutions
 
   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 1,058 0 0 0 0 1,058
Annual IC Time Burden (Hours) 1,058 0 0 0 0 1,058
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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