Information Collection

CRU Form Sample with screen shots

IC 212595 under ICR 201708-0925-001 · OMB 0925-0705.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0705 can be found here:

Documents and Forms

Document Name Document Type
Form 1 CRU Form Sample with screen shots Form and Instruction
1 CRU Form Sample w screenshots Attach 9_CRU Form Sample w screen shots (6).pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	CRU Form Sample with screen shots	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	CRU Form Sample w screenshots	Attach 9_CRU Form Sample w screen shots (6).pdf		No		Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 20	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	Previously Approved
Annual Number of Responses for this IC	20	20
Annual IC Time Burden (Hours)	10	10
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.