Checklist for Adding a new Service Delivery Site

The Health Center Program Application Forms

OMB: 0915-0285

IC ID: 193525

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

Checklist for Adding a new Service Delivery Site
 
No Unchanged
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 3 Checklist for Adding a New Service Delivery Site - Clean.docx Checklist for Adding a New Service Delivery Site - Clean.docx Yes Yes Fillable Fileable
Form and Instruction 3E Checklist for Adding a New Service Delivery Site edits.docx Checklist for Adding a New Service Delivery Site edits.docx Yes Yes Fillable Fileable

Health Health Care Services

 

1,480 0
   
Private Sector Not-for-profit institutions
 
   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 1,480 0 0 0 0 1,480
Annual IC Time Burden (Hours) 2,960 0 0 0 0 2,960
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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