Information Collection

Attachment 4. Medical Complications Reporting Form and Instructions

IC 179136 under ICR 200703-0920-006 · OMB 0920-0745.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0745 can be found here:

Documents and Forms

Document Name Document Type
Attachment 4. Medical Complications Reporting Form and Instructions Form and Instruction
Medical Complications Reporting Form 0920-05CJ ATTACHMENT 4 Medical Comp Form.doc Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Attachment 4. Medical Complications Reporting Form and Instructions	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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	None	Medical Complications Reporting Form	0920-05CJ ATTACHMENT 4 Medical Comp Form.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	30	30
Annual IC Time Burden (Hours)	30	30
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.