Information Collection

57.404 Outpatient Procedure Component - SSI Denominators

IC 228153 under ICR 201708-0920-029 · OMB 0920-0666.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0666 can be found here:

Documents and Forms

Document Name Document Type
Form 57.404 57.404 Outpatient Procedure Component - SSI Denominators Form
57.404 Outpatient Procedure Component - SSI Denominators 57.404_OPC_DenomSSI_BLANK.DOCX Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	57.404 Outpatient Procedure Component - SSI Denominators	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	57.404	Outpatient Procedure Component - SSI Denominators	57.404_OPC_DenomSSI_BLANK.DOCX		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,700,000	2,700,000
Annual IC Time Burden (Hours)	450,000	450,000
Annual IC Cost Burden (Dollars)	17,820,000	17,820,000

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.