Information Collection

Appx N_ Release of Information (HIPPA) (M/FF/CW)

IC 243423 under ICR 202310-0920-010 · OMB 0920-1331.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1331 Appx N_ Release of Information (HIPPA) (M/FF/CW)	Form
0920-1331 Release of Information (HIPAA Privacy Authorization Form Appendix N Release of Information (HIPAA).docx	Form
0920-1331 Release of Information (HIPAA Privacy Authorization Form Appendix N Release of Information (HIPAA).docx	Form

IC Title:

Agency IC Tracking Number:

0920-1331

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
Form	0920-1331	Release of Information (HIPAA Privacy Authorization Form)	Appendix N Release of Information (HIPAA).docx		Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	3	3
Annual IC Time Burden (Hours)	1	1
Annual IC Cost Burden (Dollars)	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.