Information Collection

Event Record (ER) Form

IC 221597 under ICR 202006-0915-005 · OMB 0915-0281.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0281 can be found here:

Documents and Forms

Document Name Document Type
Form C Event Record (ER) Form Form
C FINAL Event Record Form.docx Change memo version FINAL Event Record Form.docx Form
FINALAETC Event Record Non Substantitive Changes Memo 06232020.docx Change Memo Event Record Form IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Event Record (ER) 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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	C	FINAL Event Record Form.docx Change memo version	FINAL Event Record Form.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10,522	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	10,522	10,522
Annual IC Time Burden (Hours)	1,368	1,368
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Change Memo Event Record Form	FINALAETC Event Record Non Substantitive Changes Memo 06232020.docx	06/23/2020

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