Information Collection

Event Record (ER) Form

IC 221597 under ICR 202206-0915-001 · OMB 0915-0281.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form C Event Record (ER) Form	Form
C FINAL Event Record Form.docx Change memo version FINAL Event Record Form.docx	Form
C FINAL Event Record Form.docx Change memo version FINAL Event Record Form.docx	Form
FINALAETC Event Record Non Substantitive Changes Memo 06232020.docx Change Memo Event Record Form	IC Document
FINALAETC Event Record Non Substantitive Changes Memo 06232020.docx Change Memo Event Record Form	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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	C	FINAL Event Record Form.docx Change memo version	FINAL Event Record Form.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10,522

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
	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	-10,522	10,522
Annual IC Time Burden (Hours)	-1,368	1,368
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Change Memo Event Record Form	FINALAETC Event Record Non Substantitive Changes Memo 06232020.docx	06/23/2020

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.