Information Collection

57.129_Adult Sepsis_BLANK

IC 222892 under ICR 202104-0920-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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 57.129 57.129_Adult Sepsis_BLANK	Form
57.129 Adult Sepsis_ 57.129_Adult Sepsis_BLANK.docx	Form
57.129 Adult Sepsis_ 57.129_Adult Sepsis_BLANK.docx	Form

IC Title:

57.129_Adult Sepsis_BLANK

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	57.129	Adult Sepsis_	57.129_Adult Sepsis_BLANK.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: 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	12,500	12,500
Annual IC Time Burden (Hours)	5,208	5,208
Annual IC Cost Burden (Dollars)	206,562	206,562

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.