Information Collection

Discontinuation Notice for Provider

IC 235325 under ICR 201903-2900-022 · OMB 2900-0872.

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Information Collection (IC) Details

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IC Title:	Discontinuation Notice for Provider	Agency IC Tracking Number:	2900-NEW

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 38 CFR 17.4100

Information Collection 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: 54VA16, Health Administration Center Civilian Health and Medical Program Records-VA	FR Citation: 74 FR 34398

Number of Respondents: 152	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 75 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	152	152
Annual IC Time Burden (Hours)	25	25
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.