Information Collection

Attachment D: Hospital Information Submission Form

IC 235458 under ICR 201903-0935-002 · OMB 0935-0243.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0243 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 3 Attachment D: Hospital Information Submission Form	Form and Instruction
3 Attachment D: Hospital Information Submission Form Attachment D Hospital Information Submission Form_updated 7-15-19_.docx	Form and Instruction

IC Title:

Attachment D: Hospital Information Submission Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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 and Instruction	3	Attachment D: Hospital Information Submission Form	Attachment D Hospital Information Submission Form_updated 7-15-19_.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 300

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: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	300	300
Annual IC Time Burden (Hours)	25	25
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.