Information Collection

Hospital/care setting patients, Form 2a Eligibility Checklist

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

Documents and Forms

Documents and forms in this information collection
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

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	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 %

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.