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pdfForm Approved
OMB No. 4040-0014
Exp. Date 02/28/2015
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 4040-0014. The time required to complete this information collection is estimated to average 60 minutes per response, including the time to review instructions, search existing data
resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form,
please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer
| File Type | application/pdf |
| File Modified | 2016-02-19 |
| File Created | 2015-10-09 |