QIF Evaluative Measures Report

The Health Center Program Application Forms

Documents and Forms

Document Name Document Type
Form 11 QIF Evaluative Measures Report Form and Instruction
11 QIF Evaluative Measures Report QIF Evaluative Measures Report.docx Form and Instruction
11 QIF Evaluative Measures Report QIF Evaluative Measures Report.docx Form and Instruction

Information Collection (IC) Details

IC Title:	QIF Evaluative Measures Report	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	11	QIF Evaluative Measures Report	QIF Evaluative Measures Report.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 12	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	12	12
Annual IC Time Burden (Hours)	18	18
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.