Information Collection

Line 3 Pretest Facility Questionnaire

IC 183889 under ICR 200802-0920-012 · OMB 0920-0780.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0780 can be found here:

Documents and Forms

Document Name Document Type
Form 3 Line 3 Pretest Facility Questionnaire Form and Instruction
3 Pretest Facility Questionnaire OMB Attachment H-Pretest Facility Qx[1].061108.doc Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Line 3 Pretest Facility Questionnaire	Agency IC Tracking Number:

Is this a Common Form? Yes		IC Status: New

Obligation to Respond: Voluntary

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	3	Pretest Facility Questionnaire	OMB Attachment H-Pretest Facility Qx[1].061108.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Health Resources Utilization Statistics	FR Citation: 49 FR 37697

Number of Respondents: 25	Number of Respondents for Small Entity: 10

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	25	25
Annual IC Time Burden (Hours)	17	17
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.