Information Collection

42 CFR 495.348(e)

IC 195512 under ICR 201806-0938-007 · OMB 0938-1158.

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IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 495.348(e)

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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 28

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-56	56
Annual IC Time Burden (Hours)	-9	9
Annual IC Cost Burden (Dollars)	0	0

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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.