Information Collection

Hospital Annual Recertification

IC 190348 under ICR 201207-0915-003 · OMB 0915-0327.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0327 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1a Hospital Annual Recertification	Form and Instruction
1a Hospital Recertification Hospital Recertification.pdf	Form and Instruction
1b Recertattestation Revised Recertattestation Revised.pdf	Form and Instruction

IC Title:

Hospital Annual Recertification

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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 and Instruction	1a	Hospital Recertification	Hospital Recertification.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	1b	Recertattestation Revised	Recertattestation Revised.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,842

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	4,842	2,369	2,473
Annual IC Time Burden (Hours)	2,421	1,184	1,237
Annual IC Cost Burden (Dollars)	0	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.