Information Collection

Serious Medical Procedure (SMR) Form - For Healthcare Providers

IC 244593 under ICR 202011-0970-010 · OMB 0970-0561.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0561 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Serious Medical Procedure (SMR) Form - For Healthcare Providers	Form
1 Serious Medical Procedure (SMR) Request Form ORR Serious Medical Procedure Request (SMR) Form.docx	Form
1 Serious Medical Procedure (SMR) Request Form ORR Serious Medical Procedure Request (SMR) Form.docx	Form

IC Title:

Serious Medical Procedure (SMR) Form - For Healthcare Providers

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

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	1	Serious Medical Procedure (SMR) Request Form	ORR Serious Medical Procedure Request (SMR) Form.docx		Yes	No	Fillable Printable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title: ORR Division of Children's Services Records

FR Citation: 81 FR 46682

Number of Respondents: 195

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	195	195
Annual IC Time Burden (Hours)	43	43
Annual IC Cost Burden (Dollars)	0	0

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.