Information Collection

Phs 374

IC 217440 under ICR 201507-0925-006 · OMB 0925-0002.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0002 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 20 Attachment 18 PHS 3734 PHS 374	Form and Instruction
20 Attachment 18 PHS 3734 Attachment 18 PHS 3734 Instructions and Form.docx	Form and Instruction

IC Title:

PHS 374

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				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 479

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: 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	479	479
Annual IC Time Burden (Hours)	240	240
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.

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