Information Collection

SEARCH Medical Record Validation of Self-Report

IC 197872 under ICR 201105-0920-013 · OMB 0920-0904.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0904 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att 4b4_medical record validation cohort.pdf	Other-WORD

IC Title:

SEARCH Medical Record Validation of Self-Report

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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
Other-WORD			Att 4b4_medical record validation cohort.pdf		No	No	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: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	710	710
Annual IC Time Burden (Hours)	118	118
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.