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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.