Information Collection

Study Staff Form 10a Chart Review Inpatient Hospitalization

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Study Staff Form 10a Chart Review Inpatient Hospitalization	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	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 %

	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

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.