Information Collection

Initial Notification of Death Physician/Office Staff

IC 221833 under ICR 201606-0925-004 · OMB 0925-0414.

Documents and Forms

Document Name Document Type
Form 4 Initial Notification of Death Physician/Office Staff Form
4 Initial Notification of Death Initial Notification of Death.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Initial Notification of Death Physician/Office Staff	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	4	Initial Notification of Death	Initial Notification of Death.pdf		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Clinical, Basic and Population-based Research Studies of the National Institutes of Health (NIH)	FR Citation: 67 FR 187

Number of Respondents: 15	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	15	15
Annual IC Time Burden (Hours)	1	1
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.