Checklist for Adding New Service

The Health Center Program Application Forms

Documents and Forms

Document Name Document Type
Form 2 Checklist for Adding New Service Form and Instruction
2 Checklist for Adding New Service -Clean.docx Checklist for Adding New Service -Clean.docx Form and Instruction
2 Checklist for Adding New Service -Clean.docx Checklist for Adding New Service -Clean.docx Form and Instruction
2E Checklist for Adding New Service edits.docx Checklist for Adding New Service edits.docx Form and Instruction
2E Checklist for Adding New Service edits.docx Checklist for Adding New Service edits.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Checklist for Adding New Service	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	2	Checklist for Adding New Service -Clean.docx	Checklist for Adding New Service -Clean.docx		Yes	Yes	Fillable Fileable
Form and Instruction	2E	Checklist for Adding New Service edits.docx	Checklist for Adding New Service edits.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 450	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	450	450
Annual IC Time Burden (Hours)	900	900
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.