Information Collection

On-going Burden

IC 244741 under ICR 202210-0938-006 · OMB 0938-1412.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1412 can be found here:

Documents and Forms

Document Name Document Type

No indexed documents/forms are available for this IC yet. A refresh has been queued.

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	On-going Burden	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 422.119 42 CFR 422.120 42 CFR 431.60 42 CFR 431.70 42 CFR 438.242(b)(5) and (6) 42 CFR 457.730 42 CFR 457.760 42 CFR 457.1233(d)(2) and (3) 42 CFR 156.221

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 345	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	345	345
Annual IC Time Burden (Hours)	589,950	589,950
Annual IC Cost Burden (Dollars)	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.