Application for Certification as a Federally Qualified Health Center Look-Alike

Documents and Forms

Document Name Document Type
Form FQHCLA - 1 Application for Certification as a Federally Qualified Health Center Look-Alike Form and Instruction
FQHCLA - 1 FQHC Look Alike PIN Program Information Notice - 2003-21 - 10-9-08.pdf bphc.hrsa.gov/policy/ Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Application for Certification as a Federally Qualified Health Center Look-Alike	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	FQHCLA - 1	FQHC Look Alike PIN	Program Information Notice - 2003-21 - 10-9-08.pdf	http://bphc.hrsa.gov/policy/	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 140	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	140	140
Annual IC Time Burden (Hours)	5,500	5,500
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.