Information Collection

Request for Dispute Resolution

IC 206502 under ICR 202310-0915-003 · OMB 0915-0126.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 23 Request for Dispute Resolution	Form and Instruction
23 Request for Dispute Resolution.pdf Request for Dispute Resolution.pdf	Form and Instruction
23 Request for Dispute Resolution.pdf Request for Dispute Resolution.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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
Form and Instruction	23	Request for Dispute Resolution.pdf	Request for Dispute Resolution.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title: System of Record Notice 09-15-0054

FR Citation: 88 FR 17854

Number of Respondents: 83

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	83	9	74
Annual IC Time Burden (Hours)	664	72	592
Annual IC Cost Burden (Dollars)	0	0	0

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.