Information Collection

PHS Assignment Request Form

IC 217564 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form 14 PHS Assignment Request Form Form
14 PHS Assignment Reqest Form Attachment 5C PHS Assignment Request Form.docx Form
Attachment 5B PHS Assignment Request Instructions.docx Attachment 5B PHS Assignment Request Instructions IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	PHS Assignment Request Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	14	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: 3,354	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	3,354	3,354
Annual IC Time Burden (Hours)	1,677	1,677
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment 5B 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.