Information Collection

Disclosure Form - Revised

IC 186801 under ICR 201206-0935-003 · OMB 0935-0143.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0143 can be found here:

Documents and Forms

Document Name Document Type
Form Form #4 Disclosure Form - Revised Form and Instruction
Form #4 PSO Disclosure Statement Form Attachment G -- PSO Disclosure Statement.fin.docx www.pso.ahrq.gov/listing/disclosfm.htm Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Disclosure Form - Revised	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
Form and Instruction	Form #4	PSO Disclosure Statement Form	Attachment G -- PSO Disclosure Statement.fin.docx	http://www.pso.ahrq.gov/listing/disclosfm.htm	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 7	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	Previously Approved
Annual Number of Responses for this IC	7	7
Annual IC Time Burden (Hours)	21	21
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.