Information Collection

Subsequent Reports under 42 CFR 50.605(a)(3)(iii) and (b)(2) (Reportimg)

IC 186924 under ICR 201112-0925-005 · OMB 0925-0417.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0417 can be found here:

Documents and Forms

Document Name Document Type
Attach 2 - Instructions.doc Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Subsequent Reports under 42 CFR 50.605(a)(3)(iii) and (b)(2) (Reportimg)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			Attach 2 - Instructions.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 55	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute	Previously Approved
Annual Number of Responses for this IC	55	15	40
Annual IC Time Burden (Hours)	110	30	80
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.