Information Collection

SEED - Medical Record Abstraction

IC 178550 under ICR 200709-0920-004 · OMB 0920-0741.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0741 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form No number Appendix S.1 Medical Record Request and Script SEED - Medical Record Abstraction	Form and Instruction
No number Appendix S.1 Medical Record Request and Script Appendix S.1 Medical Record Request Script & Fax.doc	Form and Instruction

IC Title:

SEED - Medical Record Abstraction

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	No number	Appendix S.1 Medical Record Request and Script	Appendix S.1 Medical Record Request Script & Fax.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 3,456

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	17,280	17,280
Annual IC Time Burden (Hours)	4,320	4,320
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.