Information Collection

Death Notification Referral-Imminent

IC 194824 under ICR 201010-0915-001 · OMB 0915-0157.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0157 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Death Notification Death Notification Referral-Imminent	Form and Instruction
Death Notification Death Notification Referral-Imminent Death Notification Referral - Imminent.pdf	Form and Instruction
Death Referral, Imminent, and Eligible Instructions.pdf Death Referral, Imminent, and Eligible Instructions	IC Document

IC Title:

Death Notification Referral-Imminent

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

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	Death Notification Referral-Imminent	Death Notification Referral-Imminent	Death Notification Referral - Imminent.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 58

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	9,744	9,744
Annual IC Time Burden (Hours)	4,872	4,872
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Death Referral, Imminent, and Eligible Instructions	Death Referral, Imminent, and Eligible Instructions.pdf	09/14/2010

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