Hemophilia Treatment Center Factor Replacement Data Sheet

Hemophilia Treatment Center Factor Replacement Product Data Sheet

Documents and Forms

Document Name Document Type
Form Data Sheet Hemophilia Treatment Center Factor Replacement Data Sheet Form
Data Sheet Data Sheet FINALFRPdatasheet-06-22-2007.doc Form
FINALFRPDataSheetInstructions-06-22-2007.doc Instructions IC Document

Information Collection (IC) Details

IC Title:	Hemophilia Treatment Center Factor Replacement Data Sheet	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	Data Sheet	Data Sheet	FINALFRPdatasheet-06-22-2007.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 68	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	68	68
Annual IC Time Burden (Hours)	2,040	2,040
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Instructions	FINALFRPDataSheetInstructions-06-22-2007.doc	07/06/2007

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.