Information Collection

42 CFR 494.180(f)(4)(ii)

IC 209399 under ICR 202008-0938-010 · OMB 0938-0386.

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Information Collection (IC) Details

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IC Title:	42 CFR 494.180(f)(4)(ii)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 494.180If)(4)(ii)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 8,246	Number of Respondents for Small Entity: 323

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	8,246	1,246	7,000
Annual IC Time Burden (Hours)	1,374	207	1,167
Annual IC Cost Burden (Dollars)	0	0	0

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