Information Collection

EHPI-PALS Facility Survey (first time participants)

IC 205423 under ICR 201612-0920-011 · OMB 0920-0955.

Documents and Forms

Document Name Document Type
EHPI-PALS Facility Survey (first time participants) Form and Instruction
EHDI-PALS Survey Att 3 EHDI PALS screen shots.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	EHPI-PALS Facility Survey (first time participants)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 280g-1 42 CFR 241 (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	n/a	EHDI-PALS Survey	Att 3 EHDI PALS screen shots.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 200	Number of Respondents for Small Entity: 44

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	200	-200	400
Annual IC Time Burden (Hours)	30	-30	60
Annual IC Cost Burden (Dollars)	1,080	1,080	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.