Information Collection

Death Referral Data

IC 194822 under ICR 201202-0915-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form 1 Death Referral Data Form
Death Referral Data Instructions.pdf Instruction
1 Death Referral Data Death Referral Data Worksheet.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Death Referral Data	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	Death Referral Data	Death Referral Data Worksheet.pdf		Yes	Yes	Fillable Fileable
Instruction			Death Referral Data Instructions.pdf		Yes	No	Printable Only

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 %

	Approved	Previously Approved
Annual Number of Responses for this IC	696	696
Annual IC Time Burden (Hours)	6,960	6,960
Annual IC Cost Burden (Dollars)	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.