Information Collection

Notice of Availability

IC 266578 under ICR 202404-0938-004 · OMB 0938-1421.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

Notice of Availability

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 422.2267(e)(31) 42 CFR 423.2267(e

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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 270

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	540	540
Annual IC Time Burden (Hours)	1,080	1,080
Annual IC Cost Burden (Dollars)	308,000	308,000

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.