Information Collection

HIPAA Authorization [Participants of Patient-level Intervention]

IC 249769 under ICR 202109-0920-005 · OMB 0920-1361.

Documents and Forms

Document Name Document Type
HIPAA Authorization [Participants of Patient-level Intervention] Form
HIPAA Authorization Att 8d_HIPPA authorization.docx Form
HIPAA Authorization Att 8d_HIPPA authorization.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	HIPAA Authorization [Participants of Patient-level Intervention]	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	n/a	HIPAA Authorization	Att 8d_HIPPA authorization.docx		No		Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: Epidemiologic Studies and Surveillance of Disease Problems:(SORN) 09-20-0136	FR Citation: 57 FR 62812

Number of Respondents: 153	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	153	153
Annual IC Time Burden (Hours)	13	13
Annual IC Cost Burden (Dollars)	277	277

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.