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Clinic Staff Cost Form
Integrating Community Pharmacists and Clinical Sites for Patient-Centered HIV Care
OMB: 0920-1019
IC ID: 216728
OMB.report
HHS/CDC
OMB 0920-1019
ICR 201505-0920-005
IC 216728
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1019 can be found here:
2016-02-18 - Revision of a currently approved collection
2015-10-06 - No material or nonsubstantive change to a currently approved collection
Documents and Forms
Document Name
Document Type
Clinic Staff Cost Form
Form
Revised Clinic Cost Form
Att 12_Clinic Cost Form_OMB comments_KB_clean copy.docx
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Clinic Staff Cost Form
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
New
Obligation to Respond:
Voluntary
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
none
Revised Clinic Cost Form
Att 12_Clinic Cost Form_OMB comments_KB_clean copy.docx
No
Paper Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Illness Prevention
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
20
Number of Respondents for Small Entity:
0
Affected Public:
State, Local, and Tribal Governments
Percentage of Respondents Reporting Electronically:
0 %
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
40
0
40
0
0
0
Annual IC Time Burden (Hours)
400
0
400
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
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.