Information Collection

Eligibility/Registration Form and Data Submission

IC 191667 under ICR 202208-0935-002 · OMB 0935-0162.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0162 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form # 1 Eligibility/Registration Form and Data Submission	Form and Instruction
Form # 1 Attachment A: Hospital Eligibility and Registration Form Attachment A - Eligibility and Registration Form - 3-1-22.docx	Form and Instruction
Form # 1 Attachment A: Hospital Eligibility and Registration Form Attachment A - Eligibility and Registration Form - 3-1-22.docx	Form and Instruction
Attachment I -- Emails for Hospital SOPS Data Submission.doc Attachment I -- Emails for Hospital SOPS Data Submission	IC Document
Attachment I -- Emails for Hospital SOPS Data Submission.doc Attachment I -- Emails for Hospital SOPS Data Submission	IC Document
Attachment J -- Screen Shots Hospital SOPS Forms.doc Attachment J -- Screen Shots Hospital SOPS Forms	IC Document
Attachment J -- Screen Shots Hospital SOPS Forms.doc Attachment J -- Screen Shots Hospital SOPS Forms	IC Document
Attachment K -- HSOPS Survey Data File Specifications.docx Attachment K -- HSOPS Survey Data File Specifications	IC Document
Attachment K -- HSOPS Survey Data File Specifications.docx Attachment K -- HSOPS Survey Data File Specifications	IC Document

IC Title:

Eligibility/Registration Form and Data Submission

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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
Form and Instruction	Form # 1	Attachment A: Hospital Eligibility and Registration Form	Attachment A - Eligibility and Registration Form - 3-1-22.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 340

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	340	340
Annual IC Time Burden (Hours)	17	17
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment I -- Emails for Hospital SOPS Data Submission	Attachment I -- Emails for Hospital SOPS Data Submission.doc	07/31/2013
Attachment J -- Screen Shots Hospital SOPS Forms	Attachment J -- Screen Shots Hospital SOPS Forms.doc	07/31/2013
Attachment K -- HSOPS Survey Data File Specifications	Attachment K -- HSOPS Survey Data File Specifications.docx	07/31/2013

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