Medical Treatment Facility Incident Statement

ICR 199903-0701-003

OMB: 0701-0135

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
5119 Migrated
ICR Details
0701-0135 199903-0701-003
Historical Active 199406-0701-003
DOD/AF
Medical Treatment Facility Incident Statement
Reinstatement without change of a previously approved collection   No
Regular
Approved without change 06/24/1999
Retrieve Notice of Action (NOA) 03/26/1999
  Inventory as of this Action Requested Previously Approved
06/30/2002 06/30/2002
13,200 0 0
1,056 0 0
0 0 0

This form is used by respondents (hospitals employees, including non-governmental personnel and contractors) to report specific incidents. It identifies potential risks in a facility.

None
None


No

1
IC Title Form No. Form Name
Medical Treatment Facility Incident Statement 765

  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 13,200 0 0 13,200 0 0
Annual Time Burden (Hours) 1,056 0 0 1,056 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
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.
03/26/1999


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