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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.