Information Collection

Non Participant Components

IC 182193 under ICR 200709-0925-003 · OMB 0925-0584.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0584 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Non Participant Components	Form and Instruction
1 Letter Physician Letter_Follow-up.doc	Form and Instruction
2 Qx Physician Qx_9-11-07.doc	Form and Instruction

IC Title:

Non Participant Components

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	1	Letter	Physician Letter_Follow-up.doc		Yes	Yes	Paper Only
Form and Instruction	2	Qx	Physician Qx_9-11-07.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,333

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	5,333	5,333
Annual IC Time Burden (Hours)	2,667	2,667
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.