Information Collection

42 CFR 50.604(d) or 45 CFR 94.4 for Institutions (Disclosure)

IC 200593 under ICR 201809-0925-001 · OMB 0925-0417.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0417 can be found here:

Documents and Forms

Document Name Document Type
Attach 4 - Instructions (3).doc Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	42 CFR 50.604(d) or 45 CFR 94.4 for Institutions (Disclosure)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 50.604(d)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			Attach 4 - Instructions (3).doc		No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	3,000	3,000
Annual IC Time Burden (Hours)	3,000	3,000
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.