Information Collection

57.101 Facility Contact Information

IC 183570 under ICR 202212-0920-013 · OMB 0920-0666.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0666 can be found here:

Documents and Forms

Document Name Document Type
Form CDC 57.101 57.101 Facility Contact Information Form
Form CDC 57.101 57.101 Facility Contact Information Form
CDC 57.101 Facility Contact Information 57.101_FacConInf_BLANK.docx Form
CDC 57.101 Facility Contact Information 57.101_FacConInf_BLANK.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	57.101 Facility Contact Information	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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	CDC 57.101	Facility Contact Information	57.101_FacConInf_BLANK.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,000	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	2,000	2,000
Annual IC Time Burden (Hours)	333	333
Annual IC Cost Burden (Dollars)	13,220	13,220

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.