Information Collection

Release Request (Form R-4) - Modernized UC Portal - Care Provider

IC 264189 under ICR 202401-0970-003 · OMB 0970-0552.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0552 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form R-4 Release Request (Form R-4) - Modernized UC Portal - Care Provider	Form and Instruction
R-4 Release Request - Modernized UC Portal Version Program Exit Processing (Form R-10) - Modernized UC Portal.docx	Form and Instruction
R-4 Release Request - Modernized UC Portal Version Program Exit Processing (Form R-10) - Modernized UC Portal.docx	Form and Instruction

IC Title:

Release Request (Form R-4) - Modernized UC Portal - Care Provider

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

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	R-4	Release Request - Modernized UC Portal Version	Program Exit Processing (Form R-10) - Modernized UC Portal.docx		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title: 09-80-0321 ORR Division of Children's Services Records

FR Citation: 81 FR 46682

Number of Respondents: 300

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	129,000	129,000
Annual IC Time Burden (Hours)	74,820	74,820
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.