Information Collection

NSRCF - Verification Form

IC 183892 under ICR 200911-0920-003 · OMB 0920-0780.

Documents and Forms

Document Name Document Type
Attachment N-Verification Form.doc Other-WORD

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	NSRCF - Verification Form	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 N-Verification Form.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: 113	Number of Respondents for Small Entity: 30

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	113	-637	750
Annual IC Time Burden (Hours)	9	-179	188
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.