OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Request for Medical Record Abstraction

IC 239065 under ICR 202305-0923-001 · OMB 0923-0063.

Documents and Forms
Document Name
Document Type
Other-Letter of Request to Provider
Other-Letter of Request to Provider
Information Collection (IC) Details

View Information Collection (IC)

Request for Medical Record Abstraction
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Letter of Request to Provider with Study Information M_Att17_ReqstMedRecAbstrctn_20191212_updt.docx No   Paper Only

Health Public Health Monitoring

SORN 09–19–0001, ‘‘Records of Persons Exposed or Potentially Exposed to Toxic or Hazardous Substances"  76 FR 4432

70 70
   
Private Sector Businesses or other for-profits
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 3,010 0 0 0 0 3,010
Annual IC Time Burden (Hours) 1,003 0 0 0 0 1,003
Annual IC Cost Burden (Dollars) 54,860 0 0 0 0 54,860

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.