INDIAN HEALTH SERVICE CONTRACT HOSPITAL INPATIENT REPORT

ICR 198308-0915-006

OMB: 0915-0021

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
110065 Migrated
ICR Details
0915-0021 198308-0915-006
Historical Active 198107-0915-002
HHS/HSA
INDIAN HEALTH SERVICE CONTRACT HOSPITAL INPATIENT REPORT
Revision of a currently approved collection   No
Regular
Approved without change 10/11/1983
Retrieve Notice of Action (NOA) 08/18/1983
  Inventory as of this Action Requested Previously Approved
09/30/1984 09/30/1984 09/30/1983
50,000 0 50,000
8,333 0 8,333
0 0 0

PROVIDES A DESCRIPTION OF THE PATIENT'S DISGNOSIS UPON ADMISSION, OPERATIVE AND SELECTED PROCEDURES PERFORMED, INJURY DATA (WHEN APPLICABLE) AND FEE CHARGED. SERVES AS A LEGAL DOCUMENT FOR HEALTH CARE RENDERED. COPIES OF THE FORM ARE ALSO USED FOR BILLING PURPOSES AND PROGRAM HEALTH STATISTICS.

None
None


No

1
IC Title Form No. Form Name
INDIAN HEALTH SERVICE CONTRACT HOSPITAL INPATIENT REPORT HSA-43

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 50,000 50,000 0 0 0 0
Annual Time Burden (Hours) 8,333 8,333 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
08/18/1983


© 2024 OMB.report | Privacy Policy