Information Collection

EHPI-PALS Facility Survey (first time participants)

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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

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:

table that charts list of 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 %

table that charts list of burden
	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

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.