Information Collection

EHPI-PALS Facility Survey

IC 205423 under ICR 201402-0920-002 · OMB 0920-0955.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0955 can be found here:

Documents and Forms

Document Name Document Type
Att 4_revisedSurvey (word).docx Other-WWORD
Att 4a_revisedSurvey_EHDI_PALS-v4.docx Other-WORD

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	EHPI-PALS Facility Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 241 42 CFR 280f (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-WWORD			Att 4_revisedSurvey (word).docx		Yes	Yes	Printable Only
Other-WORD			Att 4a_revisedSurvey_EHDI_PALS-v4.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 400	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	400	-1,100	1,500
Annual IC Time Burden (Hours)	60	-165	225
Annual IC Cost Burden (Dollars)	0	0	0

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.