Information Collection

416-1

IC 217567 under ICR 201708-0925-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form 19 416-1 Form and Instruction
Attachment 7A PHS 416-1 Instructions.docx Instruction
19 Attachment 7B PHS 416-1 Face Page 1 Attachment 7B PHS 416-1 Face Page 1.docx Form and Instruction
20 Attachment 7C PHS 416-1 Face Page 2 Attachment 7C PHS 416-1 Face Page 2.docx Form and Instruction
21 Attachment 7D PHS 416-1 Face Page 3 Attachment 7D PHS 416-1 Face Page 3.docx Form and Instruction
22 Attachment 7E PHS 416-1 Face Page 4 Attachment 7E PHS 416-1 Face Page 4.docx Form and Instruction
23 Attachment 7F PHS 416-1 Checklist Form Page Attachment 7F PHS 416-1 Checklist Form Page.docx Form and Instruction
24 Attachment 7G PHS 416-1 Continuation Page Attachment 7G PHS 416-1 Continuation Page.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	416-1	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	19	Attachment 7B PHS 416-1 Face Page 1	Attachment 7B PHS 416-1 Face Page 1.docx	Yes	Yes	Fillable Fileable
Instruction			Attachment 7A PHS 416-1 Instructions.docx	Yes	Yes	Paper Only
Form and Instruction	20	Attachment 7C PHS 416-1 Face Page 2	Attachment 7C PHS 416-1 Face Page 2.docx	Yes	Yes	Fillable Fileable
Form and Instruction	21	Attachment 7D PHS 416-1 Face Page 3	Attachment 7D PHS 416-1 Face Page 3.docx	Yes	Yes	Fillable Fileable
Form and Instruction	22	Attachment 7E PHS 416-1 Face Page 4	Attachment 7E PHS 416-1 Face Page 4.docx	Yes	Yes	Fillable Fileable
Form and Instruction	23	Attachment 7F PHS 416-1 Checklist Form Page	Attachment 7F PHS 416-1 Checklist Form Page.docx	Yes	Yes	Fillable Fileable
Form and Instruction	24	Attachment 7G PHS 416-1 Continuation Page	Attachment 7G PHS 416-1 Continuation Page.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 29	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	29	29
Annual IC Time Burden (Hours)	290	290
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.