Information Collection

Study Staff Form 10a Chart Review Inpatient Hospitalization

IC 218296 under ICR 201509-0925-002 · OMB 0925-0737.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 28 Study Staff Form 10a Chart Review Inpatient Hospitalization	Form
28 Attachment 12 Form 10a Chart Review -Inpatient Hospitali Attachment 12 -Form10a Chart Review - Inpatient Hospitalization.docx	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	28	Attachment 12 Form 10a Chart Review -Inpatient Hospitalization	Attachment 12 -Form10a Chart Review - Inpatient Hospitalization.docx		No		Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5

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	3,000	3,000
Annual IC Time Burden (Hours)	500	500
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.