APPLICATION TO PARTICIPATE IN THE HEALTH PROFESSIONS CAPITATION PROGRAM

ICR 198509-0915-003

OMB: 0915-0089

Federal Form Document

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Document
Name
Status
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ICR Details
0915-0089 198509-0915-003
Historical Active 198503-0915-003
HHS/HSA
APPLICATION TO PARTICIPATE IN THE HEALTH PROFESSIONS CAPITATION PROGRAM
Extension without change of a currently approved collection   No
Regular
Approved without change 11/13/1985
Retrieve Notice of Action (NOA) 09/18/1985
THIS REQUEST FOR CLEARANCE IS NOT APPROVED BECAUSE IT DOES NOT REFLECT RECENT STATUTORY CHANGES IN THE PROGRAM. THE EARLIER CLEARANCE PERIOD IS EXTENDED THRU MARCH 1986. FUTURE REQUESTS FOR CLEARANCE SHOULD INCLUDE A DATA ELEMENT DESIGNED TO DEMONSTRATE ACTUAL END OF YEAR ENROLLMENT FOR THE PRECEEDING YEAR IN ADDITION TO REVISIONS REFLECTING RECENT STATUTORY CHANGES.
  Inventory as of this Action Requested Previously Approved
03/31/1986 03/31/1986 12/31/1985
23 0 23
138 0 138
0 0 0

GRANTS. HEALTH. FORM AND INSTRUCTIONS ARE NEEDED TO ENABLE ELIGIBLE SCHOOLS OF PUBLIC HEALTH TO APPLY FOR HEALTH PROFESSIONS CAPITATION GRANTS.

None
None


No

1
IC Title Form No. Form Name
APPLICATION TO PARTICIPATE IN THE HEALTH PROFESSIONS CAPITATION PROGRAM HRSA-528

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 23 23 0 0 0 0
Annual Time Burden (Hours) 138 138 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
09/18/1985


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