Information Collection

Pulling and re-filing Patient Record form (Line 4)

IC 181891 under ICR 201111-0920-001 · OMB 0920-0234.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0234 can be found here:

Documents and Forms

Document Name Document Type
Att T Pulling and Re-filing.pdf Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Pulling and re-filing Patient Record form (Line 4)	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
Instruction			Att T Pulling and Re-filing.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title: 09-20-0167 Health Resources Utilization Statistics	FR Citation: 49 FR 37693

Number of Respondents: 12,989	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: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	389,670	362,880	26,790
Annual IC Time Burden (Hours)	6,495	6,048	447
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.