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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form 1 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

Information Collection (IC) Details

View Information Collection (IC)

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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	GDC Data Submission Request Form	Attachment 1 GDC_Data_Submission_Request_Form.pdf		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 %

	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

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.