Uniform Data System

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0193 can be found here:

Documents and Forms

Document Name Document Type
Form Table 3B Uniform Data System Form
Table 3B Race Ethnicity Collection Revised RaceEthnicityTable.doc Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Uniform Data System	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 51c 42 CFR 56 (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	Table 3B	Race Ethnicity Collection	Revised RaceEthnicityTable.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,076	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,076	0	1,076
Annual IC Time Burden (Hours)	67,988	1,076	66,912
Annual IC Cost Burden (Dollars)	97,300	0	97,300

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.