Information Collection

Request for Medical Record Abstraction

IC 239065 under ICR 202010-0923-002 · OMB 0923-0063.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0063 can be found here:

Documents and Forms

Document Name Document Type
M_Att17_ReqstMedRecAbstrctn_20191212.docx Other-Letter of Request to Provider

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Request for Medical Record Abstraction	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Letter of Request to Provider with Study Information			M_Att17_ReqstMedRecAbstrctn_20191212.docx		No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: SORN 09â19â0001, ââRecords of Persons Exposed or Potentially Exposed to Toxic or Hazardous Substances"	FR Citation: 76 FR 4432

Number of Respondents: 70	Number of Respondents for Small Entity: 70

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

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	3,010	3,010
Annual IC Time Burden (Hours)	1,003	1,003
Annual IC Cost Burden (Dollars)	54,860	54,860

Documents for IC

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.