Information Collection

Heart, Lung, Heart/Lung Follow Up (6 month)

IC 214126 under ICR 201411-0915-004 · OMB 0915-0157.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0157 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 20 Heart, Lung, Heart/Lung Follow Up (6 month)	Form and Instruction
20 Heart, Lung, Heart/Lung Follow Up (6 month) 20 Thoracic 6 Month Recipient Follow_Heart_Lung_ Instructions.docx	Form and Instruction

IC Title:

Heart, Lung, Heart/Lung Follow Up (6 month)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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	20	Heart, Lung, Heart/Lung Follow Up (6 month)	20 Thoracic 6 Month Recipient Follow_Heart_Lung_ Instructions.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 259

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 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,923	3,923
Annual IC Time Burden (Hours)	3,138	3,138
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.