Information Collection

Support for Medical Record Abstraction

IC 221997 under ICR 201802-0920-004 · OMB 0920-1162.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1162 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Support for Medical Record Abstraction	Form
Medical Record Abstraction Attachment 9. Chart Abstraction Form.docx	Form

IC Title:

Support for Medical Record Abstraction

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	none	Medical Record Abstraction	Attachment 9. Chart Abstraction Form.docx		No		Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,002

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: 0 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	1,002	1,002
Annual IC Time Burden (Hours)	84	84
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.