Information Collection

Section 1921 forms

IC 199299 under ICR 201304-0915-002 · OMB 0915-0126.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0126 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2 Section 1921 forms	Form and Instruction
2 60.10: Adverse Actions - Private Accreditation Accreditation Initial - Organization Subject.pdf	Form and Instruction
1 60.9: Licensure Actions State Licensure Initial - Individual Subject.pdf	Form and Instruction
3 60.10: Adverse Actions - Peer Review Organizations Peer Review Organization Initial - Individual Subject.pdf	Form and Instruction

IC Title:

Section 1921 forms

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	2	60.10: Adverse Actions - Private Accreditation	Accreditation Initial - Organization Subject.pdf	Yes	Yes	Fillable Fileable Signable
Form and Instruction	1	60.9: Licensure Actions	State Licensure Initial - Individual Subject.pdf	Yes	Yes	Fillable Fileable Signable
Form and Instruction	3	60.10: Adverse Actions - Peer Review Organizations	Peer Review Organization Initial - Individual Subject.pdf	Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 39

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-61	61
Annual IC Time Burden (Hours)	-46	46
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.