Information Collection

Provision of patient lists

IC 212547 under ICR 201608-0920-019 · OMB 0920-0852.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0852 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Provision of Patients ListForm Approved.docx	Instruction

IC Title:

Provision of patient lists

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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
Instruction			Provision of Patients ListForm Approved.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-100	100
Annual IC Time Burden (Hours)	-400	400
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.