Information Collection

Prepare and Transmit UB-04 Files

IC 202431 under ICR 201205-0920-009 · OMB 0920-0944.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 4 Prepare and Transmit UB-04 Files	Form
4 Performance of Colonoscopy in the United States Att N - NHCS Ambulatory Pretest Colonoscopy Form.pdf	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

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
Form	4	Performance of Colonoscopy in the United States	Att N - NHCS Ambulatory Pretest Colonoscopy Form.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title: Health Resources Utilization Statistics

FR Citation: 49 FR 37693

Number of Respondents: 47

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 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	47	47
Annual IC Time Burden (Hours)	47	47
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.