Information Collection

Pulling, re-filing medical record forms (FR abstracts) (2020)

IC 213884 under ICR 202105-0920-006 · OMB 0920-0234.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0234 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0234 Pulling, re-filing medical record forms (FR abstracts) (2020)	Form
0920-0234 Att R- 2021 EHR Pulling Records Burden Att O1-2021 PRF Burden Abstract.docx	Form
0920-0234 Att R- 2021 EHR Pulling Records Burden Att O1-2021 PRF Burden Abstract.docx	Form
0920-0234 PRF Burden Abstract Att O2-2021 PRF Burden Abstract.docx	Form and Instruction
0920-0234 PRF Burden Abstract Att O2-2021 PRF Burden Abstract.docx	Form and Instruction

IC Title:

Pulling, re-filing medical record forms (FR abstracts) (2020)

Agency IC Tracking Number:

0920-0234

Is this a Common Form? No

IC Status: Modified

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	0920-0234	Att R- 2021 EHR Pulling Records Burden	Att O1-2021 PRF Burden Abstract.docx		Yes	Yes	Fillable Fileable
Form and Instruction	0920-0234	PRF Burden Abstract	Att O2-2021 PRF Burden Abstract.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20--0167 Health Resources Utilization Statistics

FR Citation: 49 FR 37697

Number of Respondents: 52

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: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,560	-28,200	29,760
Annual IC Time Burden (Hours)	26	-470	496
Annual IC Cost Burden (Dollars)	0	-16,070	16,070

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.