Information Collection

Phs 568

IC 217415 under ICR 202207-0925-004 · OMB 0925-0002.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0002 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 3 PHS 568	Form and Instruction
3 HHS 568 Attachment 15 HHS 568 Instructions and form_FORMS-G.docx	Form and Instruction
3 HHS 568 Attachment 15 HHS 568 Instructions and form_FORMS-G.docx	Form and Instruction

IC Title:

PHS 568

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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	3	HHS 568	Attachment 15 HHS 568 Instructions and form_FORMS-G.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 11,180

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	11,180	11,180
Annual IC Time Burden (Hours)	932	932
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.