Information Collection

Data Collection Instrument

IC 237749 under ICR 201909-0935-001 · OMB 0935-0244.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0244 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Data Collection Instrument	Form and Instruction
1 Data Collection Instrument Attachment B.docx	Form and Instruction

IC Title:

Data Collection Instrument

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	1	Data Collection Instrument	Attachment B.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 382

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: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	382	382
Annual IC Time Burden (Hours)	13	13
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.