Information Collection

Physician/Office Staff

IC 188611 under ICR 201306-0925-001 · OMB 0925-0414.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0414 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 120 Physician/Office Staff	Form and Instruction
120 Initial Notification of Death F120V8.1.pdf	Form and Instruction

IC Title:

Physician/Office Staff

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
Form and Instruction	120	Initial Notification of Death	F120V8.1.pdf		No	No	Printable Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 17

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	17	9	8
Annual IC Time Burden (Hours)	1	0	1
Annual IC Cost Burden (Dollars)	0	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.