Information Collection

Hospital Data Abstraction Form

IC 206303 under ICR 201303-0930-003 · OMB 0930-0337.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0337 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Hospital Data Abst Hospital Data Abstraction Form	Form and Instruction
Hospital Data Abst Hospital Data Abstraction Form Attachment A_Hospital Data Abstraction Form.docx	Form and Instruction

IC Title:

Hospital Data Abstraction Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	Hospital Data Abstraction Form	Hospital Data Abstraction Form	Attachment A_Hospital Data Abstraction Form.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	667	667
Annual IC Time Burden (Hours)	27	27
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.