Information Collection

Private Sector

IC 261973 under ICR 202307-0938-001 · OMB 0938-1281.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1281 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	Private Sector	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 438.515(a)(1) and (a)(2) 42 CFR 438.520(a)(2)(iv) and(a)(3)(v) 42 CFR 457.1240(d)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 629	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,145	3,145
Annual IC Time Burden (Hours)	1,349,834	1,349,834
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.