Information Collection

PHS 398 Cover Page Supplement

IC 202963 under ICR 201705-0925-009 · 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⚠️ Notice: This information collection may be referencing outdated material.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 4 PHS 398 Cover Page Supplement	Form
4 PHS 398 Cover Page Supplement Form Attachment 5E PHS 398 Cover Page Supplement Form.docx	Form
Attachment 5D PHS 398 Cover Page Supplement Instructions.docx Attachment 5D PHS 398 Cover Page Supplement Instructions	IC Document

IC Title:

PHS 398 Cover Page Supplement

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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	4	PHS 398 Cover Page Supplement Form	Attachment 5E PHS 398 Cover Page Supplement Form.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 74,239

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	74,239	74,239
Annual IC Time Burden (Hours)	74,239	74,239
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment 5D PHS 398 Cover Page Supplement Instructions	Attachment 5D PHS 398 Cover Page Supplement Instructions.docx	01/25/2017

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