Information Collection

Notice to Treat up to 275 Patients

IC 222812 under ICR 202105-0930-001 · OMB 0930-0234.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0234 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Waiver Form 275 pa Notice to Treat up to 275 Patients	Form and Instruction
Waiver Form 275 pa Waiver Form 275 patients Attachment C NOI 275 Waiver 9.16.19.doc	Form and Instruction

IC Title:

Notice to Treat up to 275 Patients

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 and Instruction	Waiver Form 275 patients	Waiver Form 275 patients	Attachment C NOI 275 Waiver 9.16.19.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 800

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	800	800
Annual IC Time Burden (Hours)	65	65
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.