Information Collection

Pulling and re-filing Patient Record form (Line 4)

IC 181891 under ICR 201211-0920-001 · OMB 0920-0234.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0234 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att T Pulling and Re-filing.pdf	Instruction
Att EE 2012 NAMCS Re-abstraction Study Pulling and Re-filing.pdf Att EE 2012 NAMCS Re-abstraction Study Pulling and Re-filing	IC Document

IC Title:

Pulling and re-filing Patient Record form (Line 4)

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
Instruction			Att T Pulling and Re-filing.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title: 09-20-0167 Health Resources Utilization Statistics

FR Citation: 49 FR 37693

Number of Respondents: 13,627

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 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	408,810	19,140	389,670
Annual IC Time Burden (Hours)	6,814	319	6,495
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att EE 2012 NAMCS Re-abstraction Study Pulling and Re-filing	Att EE 2012 NAMCS Re-abstraction Study Pulling and Re-filing.pdf	12/12/2011

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