Information Collection

42 CFR Institutions (Disclosure)

IC 186927 under ICR 200810-0925-005 · OMB 0925-0417.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0417 can be found here:

Documents and Forms

Document Name Document Type
Attach 2 - Instructions.doc Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	42 CFR Institutions (Disclosure)	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
Instruction			Attach 2 - Instructions.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,800	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	2,800	2,800
Annual IC Time Burden (Hours)	56,000	56,000
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.