Information Collection

Retrieving and Refiling Records - Data Elements

IC 227708 under ICR 202208-0920-014 · OMB 0920-1128.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1128 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Retrieving and Refiling Records - Data Elements	Form and Instruction
SUDORS Case Report - Retrieving and Refiling Records Att D SUDORS_Data_Elements.docx	Form and Instruction
SUDORS Case Report - Retrieving and Refiling Records Att D SUDORS_Data_Elements.docx	Form and Instruction
Att E. SUDORS_Data_Elements_ Screen Shots.docx Screen Shots for SUDORS Data Elements	IC Document
Att E. SUDORS_Data_Elements_ Screen Shots.docx Screen Shots for SUDORS Data Elements	IC Document

IC Title:

Retrieving and Refiling Records - Data Elements

Agency IC Tracking Number:

0920-1128

Is this a Common Form? No

IC Status: Modified

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	n/a	SUDORS Case Report - Retrieving and Refiling Records	Att D SUDORS_Data_Elements.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 51

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
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	87,261	21,585	65,676
Annual IC Time Burden (Hours)	43,631	10,793	32,838
Annual IC Cost Burden (Dollars)	0	-897,791	897,791

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Screen Shots for SUDORS Data Elements	Att E. SUDORS_Data_Elements_ Screen Shots.docx	09/07/2022

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