Information Collection

NSRCF - Pre-Interview Worksheet

IC 183889 under ICR 200911-0920-003 · OMB 0920-0780.

Documents and Forms

Document Name Document Type
Attachment H-Confirmation Package.doc Other-WORD

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	NSRCF - Pre-Interview Worksheet	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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
Other-WORD			Attachment H-Confirmation Package.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: 1,125	Number of Respondents for Small Entity: 300

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	Previously Approved
Annual Number of Responses for this IC	1,125	1,100	25
Annual IC Time Burden (Hours)	281	264	17
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.