Information Collection

Attestation

IC 201492 under ICR 201210-0938-005 · OMB 0938-0969.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0969 can be found here:

Documents and Forms

Document Name Document Type
PIM ADR color coded.doc Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Attestation	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 421.304 42 CFR 421.200 42 CFR 421.210

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			PIM ADR color coded.doc		Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 20,434	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	20,434	20,434
Annual IC Time Burden (Hours)	5,109	5,109
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.