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Data Use Agreement and Supplement for 2014 Health Center Patient Survey
Data Use Agreement and Supplement for 2014 Health Center Patient Survey
OMB: 0906-0027
IC ID: 224072
OMB.report
HHS/HRSA
OMB 0906-0027
ICR 201610-0906-001
IC 224072
( )
Documents and Forms
Document Name
Document Type
Form 1
Data Use Agreement and Supplement for 2014 Health Center Patient Survey
Form and Instruction
1 DUA
DUA.docx
Form and Instruction
1 DUA Supplement
DUA Supplement.docx
Form and Instruction
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Data Use Agreement and Supplement for 2014 Health Center Patient Survey
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 and Instruction
1
DUA
DUA.docx
Yes
Yes
Fillable Fileable
Form and Instruction
1
DUA Supplement
DUA Supplement.docx
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
40
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits, Not-for-profit institutions
Percentage of Respondents Reporting Electronically:
100 %
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)
30
0
30
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.