Information Collection

PHS Assignment Request Form

IC 202959 under ICR 201701-0925-003 · OMB 0925-0001.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0001 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 3 PHS Assignment Request Form	Form
3 PHS Assignment Reqest Form Attachment 5C PHS Assignment Request Form.docx	Form
Attachment 5B PHS Assignment Request Instructions.docx PHS Assignment Request Instructions	IC Document

IC Title:

PHS Assignment Request Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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
Form	3	PHS Assignment Reqest Form	Attachment 5C PHS Assignment Request Form.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 37,120

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	37,120	37,120
Annual IC Time Burden (Hours)	18,560	18,560
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
PHS Assignment Request Instructions	Attachment 5B PHS Assignment Request Instructions.docx	01/25/2017

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