Information Collection

Hospital/care setting patients, Form 1a Screening and enrollment log

IC 218246 under ICR 201509-0925-002 · OMB 0925-0737.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2 Hospital/care setting patients, Form 1a Screening and enrollment log	Form
2 Attachment 3 Form 1a Screening and Enrollment Log Attachment 3 - Form1a Screening and Enrolment Log.pdf	Form

IC Title:

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

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	2	Attachment 3 Form 1a Screening and Enrollment Log	Attachment 3 - Form1a Screening and Enrolment Log.pdf		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,600

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,600	1,600
Annual IC Time Burden (Hours)	267	267
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.