Information Collection

Hospital/care setting patients, Form 2a Eligibility Checklist

IC 218247 under ICR 201509-0925-002 · OMB 0925-0737.

Documents and Forms

Document Name Document Type
Form 3 Hospital/care setting patients, Form 2a Eligibility Checklist Form
3 Attachment 4 Form 2a Eligibility Checklist Attachment 4 -Form2a Eligibility Checklist.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Hospital/care setting patients, Form 2a Eligibility Checklist	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	3	Attachment 4 Form 2a Eligibility Checklist	Attachment 4 -Form2a Eligibility Checklist.pdf		No		Fillable Fileable

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 %

	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

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.