Information Collection

Participant Components Annual follow-up records Request

IC 221006 under ICR 201604-0925-002 · OMB 0925-0216.

Documents and Forms

Document Name Document Type
Form 1 Participant Components Annual follow-up records Request Form and Instruction
1 Attachment 5 Medical Record Request Attach 5 Medical Record Request.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Participant Components Annual follow-up records Request	Agency IC Tracking Number:

Is this a Common Form? No		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 and Instruction	1	Attachment 5 Medical Record Request	Attach 5 Medical Record Request.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 30	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	30	30
Annual IC Time Burden (Hours)	8	8
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.