Information Collection

Request for Medical Record Abstraction

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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
M_Att17_ReqstMedRecAbstrctn_20191212_updt.docx	Other-Letter of Request to Provider
M_Att17_ReqstMedRecAbstrctn_20191212_updt.docx	Other-Letter of Request to Provider

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
Other-Letter of Request to Provider with Study Information			M_Att17_ReqstMedRecAbstrctn_20191212_updt.docx		No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: SORN 09â19â0001, ââRecords of Persons Exposed or Potentially Exposed to Toxic or Hazardous Substances"

FR Citation: 76 FR 4432

Number of Respondents: 70

Number of Respondents for Small Entity: 70

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	3,010	3,010
Annual IC Time Burden (Hours)	1,003	1,003
Annual IC Cost Burden (Dollars)	54,860	54,860

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.