Information Collection

Hospital/care setting patients, Form 3a Subject Identification

IC 218248 under ICR 201509-0925-002 · OMB 0925-0737.

Documents and Forms

Document Name Document Type
Form 4 Hospital/care setting patients, Form 3a Subject Identification Form
4 Attachment 5 Form 3a Subject Indentification Attachment 5 -Form3a Subject Identification.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Hospital/care setting patients, Form 3a Subject Identification	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	4	Attachment 5 Form 3a Subject Indentification	Attachment 5 -Form3a Subject Identification.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.