Information Collection

42CFR484.642(c)

IC 219099 under ICR 201511-0938-011 · OMB 0938-1307.

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Information Collection (IC) Details

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IC Title:	42CFR484.642(c)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 484.642(c)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,328	Number of Respondents for Small Entity: 1,328

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 75 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	150,000	150,000
Annual IC Time Burden (Hours)	10,950	10,950
Annual IC Cost Burden (Dollars)	0	0

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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.