Information Collection

Request for a Temporary Patient Increase Patient Increase for an Emergency - 8.655

IC 222817 under ICR 202211-0930-002 · OMB 0930-0234.

Documents and Forms

Document Name Document Type
No form.docx Instruction
No form.docx Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Request for a Temporary Patient Increase Patient Increase for an Emergency - 8.655	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
Instruction			No form.docx		No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 12	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	36	26	10
Annual IC Time Burden (Hours)	108	78	30
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.