Information Collection

Facility Staff Medical Record Abstraction

IC 180565 under ICR 200904-0920-003 · OMB 0920-0740.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0740 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment6_aMHF.doc	Instruction
Attachment6c_SPSummary Form.doc	Instruction
Attachment6b_SPIF.doc	Instruction
Attachment6d_SPVisit Form.doc	Instruction
atachment4c_MinimalData.doc	Instruction

IC Title:

Facility Staff Medical Record Abstraction

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction	Attachment6_aMHF.doc	Yes	No	Printable Only
Instruction	Attachment6c_SPSummary Form.doc	Yes	Yes	Printable Only
Instruction	Attachment6b_SPIF.doc	Yes	Yes	Printable Only
Instruction	Attachment6d_SPVisit Form.doc	Yes	Yes	Printable Only
Instruction	atachment4c_MinimalData.doc	Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,488

Number of Respondents for Small Entity: 7,488

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 95 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	7,488	7,488
Annual IC Time Burden (Hours)	374	374
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.