Information Collection

Attachment 4. Medical Complications Reporting Form and Instructions

IC 179136 under ICR 201004-0920-014 · OMB 0920-0745.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0745 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment 4. Medical Complications Reporting Form and Instructions	Form and Instruction
Medical Complications Reporting Form 0920-05CJ ATTACHMENT 4 Medical Comp Form.doc	Form and Instruction

IC Title:

Attachment 4. Medical Complications Reporting Form and Instructions

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

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 and Instruction	None	Medical Complications Reporting Form	0920-05CJ ATTACHMENT 4 Medical Comp Form.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-30	30
Annual IC Time Burden (Hours)	-30	30
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.