Emergency Department Visits Form

Environmental Public Health Tracking Network (Tracking Network)

OMB: 0920-1175

IC ID: 222533

Documents and Forms
Information Collection (IC) Details

View Information Collection (IC)

Emergency Department Visits Form
 
No Modified
 
Mandatory
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction none Emergency Department Visits Att4d_EmergencyDepartmentVisits_2019_clean.docx Yes Yes Fillable Fileable

Health Public Health Monitoring

 

26 0
   
State, Local, and Tribal Governments
 
   100 %

  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 26 0 0 0 0 26
Annual IC Time Burden (Hours) 2,080 0 0 0 0 2,080
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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

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