Information Collection

57.101 Facility Contact Information

IC 183570 under ICR 202010-0920-016 · OMB 0920-0666.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0666 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CDC 57.101 57.101 Facility Contact Information	Form
CDC 57.101 Facility Contact Information 57.101_FacConInf_BLANK.docx	Form

IC Title:

57.101 Facility Contact Information

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Voluntary

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	CDC 57.101	Facility Contact Information	57.101_FacConInf_BLANK.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	2,000	2,000
Annual IC Time Burden (Hours)	333	333
Annual IC Cost Burden (Dollars)	13,220	13,220

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.