Information Collection

PHS Inclusion Enrollment Report

IC 217565 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⚠️ Notice: This information collection may be referencing outdated material.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 1 PHS Inclusion Enrollment Report	Form and Instruction
Attachment 5F PHS Inclusion Enrollment Report Instructions.docx	Instruction
1 Attachment 5G PHS Inclusion Enrollment Report Attachment 5G PHS Inclusion Enrollment Report Form.docx	Form and Instruction

IC Title:

PHS Inclusion Enrollment Report

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

Obligation to Respond: Required to Obtain or Retain Benefits

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 and Instruction	1	Attachment 5G PHS Inclusion Enrollment Report	Attachment 5G PHS Inclusion Enrollment Report Form.docx		Yes	Yes	Fillable Fileable
Instruction			Attachment 5F PHS Inclusion Enrollment Report Instructions.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 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-3,354	3,354
Annual IC Time Burden (Hours)	-3,354	3,354
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.