Information Collection

416-1

IC 217567 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⚠️ Notice: This information collection may be referencing outdated material.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 19 416-1	Form and Instruction
Attachment 7A PHS 416-1 Instructions.docx	Instruction
19 Attachment 7B PHS 416-1 Face Page 1 Attachment 7B PHS 416-1 Face Page 1.docx	Form and Instruction
20 Attachment 7C PHS 416-1 Face Page 2 Attachment 7C PHS 416-1 Face Page 2.docx	Form and Instruction
21 Attachment 7D PHS 416-1 Face Page 3 Attachment 7D PHS 416-1 Face Page 3.docx	Form and Instruction
22 Attachment 7E PHS 416-1 Face Page 4 Attachment 7E PHS 416-1 Face Page 4.docx	Form and Instruction
23 Attachment 7F PHS 416-1 Checklist Form Page Attachment 7F PHS 416-1 Checklist Form Page.docx	Form and Instruction
24 Attachment 7G PHS 416-1 Continuation Page Attachment 7G PHS 416-1 Continuation Page.docx	Form and Instruction

IC Title:

416-1

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	19	Attachment 7B PHS 416-1 Face Page 1	Attachment 7B PHS 416-1 Face Page 1.docx	Yes	Yes	Fillable Fileable
Instruction			Attachment 7A PHS 416-1 Instructions.docx	Yes	Yes	Paper Only
Form and Instruction	20	Attachment 7C PHS 416-1 Face Page 2	Attachment 7C PHS 416-1 Face Page 2.docx	Yes	Yes	Fillable Fileable
Form and Instruction	21	Attachment 7D PHS 416-1 Face Page 3	Attachment 7D PHS 416-1 Face Page 3.docx	Yes	Yes	Fillable Fileable
Form and Instruction	22	Attachment 7E PHS 416-1 Face Page 4	Attachment 7E PHS 416-1 Face Page 4.docx	Yes	Yes	Fillable Fileable
Form and Instruction	23	Attachment 7F PHS 416-1 Checklist Form Page	Attachment 7F PHS 416-1 Checklist Form Page.docx	Yes	Yes	Fillable Fileable
Form and Instruction	24	Attachment 7G PHS 416-1 Continuation Page	Attachment 7G PHS 416-1 Continuation Page.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 29

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	29	29
Annual IC Time Burden (Hours)	290	290
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.