Information Collection

2017-2018 - Refusals – All Facility Types

IC 207991 under ICR 201507-0910-012 · OMB 0910-0744.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0910-0744 can be found here:

Documents and Forms

Document Name Document Type
ATTACHMENT C DATA COLLECTION FORM 7-30-2015.doc Other-Survey
ATTACHMENT B DATA COLLECTION MARKING INSTRUCTIONS 7-30-2015.doc Other-Instructions

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	2017-2018 - Refusals â All Facility Types	Agency IC Tracking Number:	ORA

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 21 CFR 5.10(a)(2)and(4)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Survey			ATTACHMENT C DATA COLLECTION FORM 7-30-2015.doc		Yes	Yes	Fillable Fileable
Other-Instructions			ATTACHMENT B DATA COLLECTION MARKING INSTRUCTIONS 7-30-2015.doc		Yes	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 16	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	16	14	2
Annual IC Time Burden (Hours)	1	-1	2
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.