Information Collection

Hospital Discharge Injury Indicators

IC 249952 under ICR 202110-0920-010 · OMB 0920-1365.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1365 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-21GB Hospital Discharge Injury Indicators	Form and Instruction
0920-21GB Hospital Discharge Injury Indicators Attachment J_Hospital Discharge Injury Indicators Spreadsheet_2018_CC_submission_01.xlsx	Form and Instruction

IC Title:

Hospital Discharge Injury Indicators

Agency IC Tracking Number:

0920-21GB

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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	0920-21GB	Hospital Discharge Injury Indicators	Attachment J_Hospital Discharge Injury Indicators Spreadsheet_2018_CC_submission_01.xlsx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 23

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
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	23	23
Annual IC Time Burden (Hours)	115	115
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.