Information Collection

SSG Fox SPGP - Program Exit Checklist & Assessments

IC 253146 under ICR 202203-2900-009 · OMB 2900-0904.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0904 can be found here:

Documents and Forms

Document Name Document Type
Form 10-317d SSG Fox SPGP - Program Exit Checklist & Assessments Form
10-317d SSG Fox SPGP - Program Exit Checklist & Assessments SSG Fox SPGP_Program Exit Checklist_10-317d.docx Form
10-317d SSG Fox SPGP - Program Exit Checklist & Assessments SSG Fox SPGP_Program Exit Checklist_10-317d.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	SSG Fox SPGP - Program Exit Checklist & Assessments	Agency IC Tracking Number:	2900-NEW

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	10-317d	SSG Fox SPGP - Program Exit Checklist & Assessments	SSG Fox SPGP_Program Exit Checklist_10-317d.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 90	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	6,030	6,030
Annual IC Time Burden (Hours)	3,015	3,015
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.