Information Collection

57.204 Healthcare Worker Demographic Data

IC 183579 under ICR 201308-0920-010 · OMB 0920-0666.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0666 can be found here:

Documents and Forms

Document Name Document Type
Form 57.204 57.204 Healthcare Worker Demographic Data Form
57.204 Healthcare Worker Demographic Data 57.204_HCWDemographicData_BLANK.DOCX Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	57.204 Healthcare Worker Demographic Data	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	57.204	Healthcare Worker Demographic Data	57.204_HCWDemographicData_BLANK.DOCX		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50	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: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	10,000	9,900	100
Annual IC Time Burden (Hours)	3,333	-3,334	6,667
Annual IC Cost Burden (Dollars)	132,833	-131,767	264,600

Documents for IC

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.