Information Collection

Sections 493.1252 and 493.1254

IC 225806 under ICR 202401-0938-001 · OMB 0938-0612.

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Information Collection (IC) Details

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IC Title:	Sections 493.1252 and 493.1254	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 493.1252 and 493.1254

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: 77,392	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	56,496,160	8,292,070	48,204,090
Annual IC Time Burden (Hours)	2,476,544	363,488	2,113,056
Annual IC Cost Burden (Dollars)	0	0	0

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