Information Collection

Patient Assessment

IC 195477 under ICR 201401-0938-015 · OMB 0938-1066.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1066 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	Patient Assessment	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 484.250

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 9,890	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	9,890	0	9,890
Annual IC Time Burden (Hours)	158,240	0	158,240
Annual IC Cost Burden (Dollars)	0	-39,560,000	39,560,000

Documents for IC

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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.