OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Follow-up to Request for Clinical & Medical Treatment Records

IC 214198 under ICR 202306-3095-005 · OMB 3095-0039.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Follow-up to Request for Clinical & Medical Treatment Records
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction NA For 13177 Check the Status of a Clinical & Medical & Treatment Records Request NA13177_06_2017_3095-0039.pdf https://www.archives.gov/forms/st-louis/clinical-followup.html Yes Yes Fillable Fileable

Education Cultural and Historic Preservation

 

1 0
   
Individuals or Households
 
   100 %

  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 1 0 -499 0 0 500
Annual IC Time Burden (Hours) 0 0 -25 0 0 25
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Explanation_June_2023 Explanation_June_2023.docx 06/15/2023
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.