Information Collection

Field Feasibility Test Hospital Records Form

IC 225822 under ICR 201702-0920-008 · OMB 0920-1176.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Field Feasibility Test Hospital Records Form	Form and Instruction
Hospitalization Record Return Form Att 8b_Request Hospital Record_170209.docx	Form and Instruction
Att 8a_Hospital Records Info_170209.docx Participant Information Sheet about the Hospital Records Request	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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 and Instruction	N/A	Hospitalization Record Return Form	Att 8b_Request Hospital Record_170209.docx		No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0167 Health Resources Utilization Statistics

FR Citation: 49 FR 37693

Number of Respondents: 360

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	360	360
Annual IC Time Burden (Hours)	120	120
Annual IC Cost Burden (Dollars)	2,787	2,787

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Participant Information Sheet about the Hospital Records Request	Att 8a_Hospital Records Info_170209.docx	02/27/2017

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