Information Collection

Notice to Treat up to 275 Patients

IC 222812 under ICR 202211-0930-002 · OMB 0930-0234.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form NOI 275 All Practi Notice to Treat up to 275 Patients	Form and Instruction
NOI 275 All Practi NOI 275 All Practitioners Waiver Attachment C-NOI 275 All Practitioners Waiver _Clean.rtf	Form and Instruction
NOI 275 All Practi NOI 275 All Practitioners Waiver Attachment C-NOI 275 All Practitioners Waiver _Clean.rtf	Form and Instruction

IC Title:

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	NOI 275 All Practitioners Waiver	NOI 275 All Practitioners Waiver	Attachment C-NOI 275 All Practitioners Waiver _Clean.rtf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 960

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	960	160	800
Annual IC Time Burden (Hours)	78	13	65
Annual IC Cost Burden (Dollars)	0	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.