Information Collection

PHS Assignment Request Form

IC 217564 under ICR 202004-0925-002 · OMB 0925-0001.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0001 can be found here:

Documents and Forms

Document Name Document Type
Form 14 PHS Assignment Request Form Form
14 PHS Assignment Request Form Attachment 5C PHS Assignment Request Form_FORMS-F.pdf Form
Attachment 5B_PHS Assignment Request Form_Instructions_FORMS-F.pdf PHS Assignment Request Instructions IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	PHS Assignment Request Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	14	PHS Assignment Request Form	Attachment 5C PHS Assignment Request Form_FORMS-F.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,354	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	3,354	3,354
Annual IC Time Burden (Hours)	1,677	1,677
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
PHS Assignment Request Instructions	Attachment 5B_PHS Assignment Request Form_Instructions_FORMS-F.pdf	12/27/2019

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