Information Collection

Uniform Data System

IC 6420 under ICR 200901-0915-001 · OMB 0915-0193.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Table 3B Race Ethnicity Collection Uniform Data System	Form
Table 3B Race Ethnicity Collection Revised RaceEthnicityTable.doc	Form

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	Table 3B				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 %

table that charts list of burden
	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

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.

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