Information Collection

CRU Form Sample with screen shots

IC 212595 under ICR 201605-0925-010 · OMB 0925-0705.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0705 can be found here:

Documents and Forms

Document Name Document Type
Form 1 CRU Form Sample with screen shots Form and Instruction
1 CRU Form Attach 6_CRU Form Sample w screen shots.docx Form and Instruction
1 Revised CRU Form REVISED Attach 6_CRU Form Sample w screen shots (6).docx Form and Instruction
Attach 7_CRU Form Guidance.pdf CRU Form Guidance IC Document
Attach 8_Draft Emails to Respondents.docx Draft Emails to Respondents IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	CRU Form Sample with screen shots	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	CRU Form	Attach 6_CRU Form Sample w screen shots.docx		Yes	Yes	Fillable Fileable
Form and Instruction	1	Revised CRU Form	REVISED Attach 6_CRU Form Sample w screen shots (6).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 20	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	Previously Approved
Annual Number of Responses for this IC	20	0	20
Annual IC Time Burden (Hours)	10	-30	40
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
CRU Form Guidance	Attach 7_CRU Form Guidance.pdf	08/06/2014
Draft Emails to Respondents	Attach 8_Draft Emails to Respondents.docx	08/06/2014

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