Information Collection

EHDI-PALS Facility Survey Opening

IC 205422 under ICR 201301-0920-005 · OMB 0920-0955.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0955 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att C_SurveyOpening.pdf	Other-WORD

IC Title:

EHDI-PALS Facility Survey Opening

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 241 42 CFR 280f (To search for a specific CFR, visit the Code of Federal Regulations.)

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
Other-WORD			Att C_SurveyOpening.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	2,000	2,000
Annual IC Time Burden (Hours)	33	33
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.