Information Collection

103(b)(5) Incident Reporting, .113 Suspension or Termination Reporting

IC 187692 under ICR 201203-0990-003 · OMB 0990-0260.

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Information Collection (IC) Details

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IC Title:	103(b)(5) Incident Reporting, .113 Suspension or Termination Reporting	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 46

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 6,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 5 %

	Approved	Previously Approved
Annual Number of Responses for this IC	3,000	3,000
Annual IC Time Burden (Hours)	2,250	2,250
Annual IC Cost Burden (Dollars)	0	0

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