Information Collection

Section 493.801 and 493.803

IC 225802 under ICR 202401-0938-001 · OMB 0938-0612.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0612 can be found here:

Documents and Forms

Document Name Document Type
SOM Appendix C.pdf Instruction
SOM Appendix C.pdf Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Section 493.801 and 493.803	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 493.801 & 493.803

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			SOM Appendix C.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 49,646	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	297,876	90,402	207,474
Annual IC Time Burden (Hours)	446,814	135,603	311,211
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.