Information Collection

PHS Assignment Request Form

IC 202959 under ICR 201602-0925-016 · OMB 0925-0001.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0001 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 PHS Assignment Request Form	Form and Instruction
1 Attachment 5C PHS Assignment Request Form Attachment 5C PHS Assignment Request Form.docx	Form and Instruction
2 PHS Assignment Request Instruction Attachment 5B PHS Assignment Request Instructions.docx	Form and Instruction

IC Title:

PHS Assignment Request Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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 and Instruction	1	Attachment 5C PHS Assignment Request Form	Attachment 5C PHS Assignment Request Form.docx		Yes	Yes	Fillable Fileable
Form and Instruction	2	PHS Assignment Request Instruction	Attachment 5B PHS Assignment Request Instructions.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 37,120

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	37,120	37,120
Annual IC Time Burden (Hours)	18,560	18,560
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.