Information Collection

Data Collection Instrument

IC 237749 under ICR 202210-0935-002 · OMB 0935-0244.

Documents and Forms

Document Name Document Type
Form 1 Data Collection Instrument Form and Instruction
1 Data Collection Instrument Attachment B.v1.docx Form and Instruction
1 Data Collection Instrument Attachment B.v1.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Data Collection Instrument	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Data Collection Instrument	Attachment B.v1.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,029	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: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,029	647	382
Annual IC Time Burden (Hours)	26	13	13
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.