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PHS Assignment Request Form
PHS Applications and Pre-award Related Reporting (OD)
OMB: 0925-0001
IC ID: 202959
OMB.report
HHS/NIH
OMB 0925-0001
ICR 201708-0925-002
IC 202959
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0001 can be found here:
2022-10-05 - Revision of a currently approved collection
2022-07-22 - No material or nonsubstantive change to a currently approved collection
Documents and Forms
Document Name
Document Type
Form 3
PHS Assignment Request Form
Form
3 PHS Assignment Reqest Form
Attachment 5C PHS Assignment Request Form.docx
Form
Attachment 5B PHS Assignment Request Instructions.docx
PHS Assignment Request Instructions
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
PHS Assignment Request Form
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Unchanged
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
3
PHS Assignment Reqest Form
Attachment 5C PHS Assignment Request Form.docx
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
37,120
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Not-for-profit institutions
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
37,120
0
0
0
0
37,120
Annual IC Time Burden (Hours)
18,560
0
0
0
0
18,560
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
PHS Assignment Request Instructions
Attachment 5B PHS Assignment Request Instructions.docx
01/25/2017
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.