Information Collection

Request for Medical Record Abstraction

IC 237378 under ICR 202110-0923-001 · OMB 0923-0061.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
P_Att19_RequestMedicalRecAbstrctn_20190813 clean.docx	Instruction
P_Att19_RequestMedicalRecAbstrctn_20190813 clean.docx	Instruction

IC Title:

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
Instruction			P_Att19_RequestMedicalRecAbstrctn_20190813 clean.docx		Yes	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Records of Persons Exposed or Potentially Exposed to Toxic or Hazardous Substances

FR Citation: 76 FR 4432

Number of Respondents: 10

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	550	550
Annual IC Time Burden (Hours)	183	183
Annual IC Cost Burden (Dollars)	10,024	10,024

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.