Information Collection

GDC Data Submission Request Form

IC 225740 under ICR 201702-0925-002 · OMB 0925-0752.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0752 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 GDC Data Submission Request Form GDC Data Submission Request Form	Form and Instruction
1 GDC Data Submission Request Form Attachment 1 GDC_Data_Submission_Request_Form.pdf	Form and Instruction

IC Title:

GDC Data Submission Request Form

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	1				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 200

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	50	50
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.

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