Information Collection

Data Request

IC 220216 under ICR 201602-0925-014 · OMB 0925-0744.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0744 can be found here:

Documents and Forms

Document Name Document Type
Form 3 Data Request Form and Instruction
3 Attachment 2-3 Data Request 0925-New_DASH_AttachmentA.2-3_DataRequest.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Data Request	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	3	Attachment 2-3 Data Request	0925-New_DASH_AttachmentA.2-3_DataRequest.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 60	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	60	60
Annual IC Time Burden (Hours)	60	60
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.