Information Collection

Medical transfer form

IC 192635 under ICR 201910-0648-008 · OMB 0648-0272.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0648-0272 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Medical transfer form	Form and Instruction
Application for emergency medical transfer of IFQ Application for medical transfer of QS_IFQ.pdf	Form and Instruction

IC Title:

Medical transfer form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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	NA	Application for emergency medical transfer of IFQ	Application for medical transfer of QS_IFQ.pdf		Yes	No	Fillable Printable

Line of Business: Natural Resources

Subfunction: Conservation, Marine and Land Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 420

Number of Respondents for Small Entity: 420

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	140	0	140
Annual IC Time Burden (Hours)	210	0	210
Annual IC Cost Burden (Dollars)	392	218	174

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.