Information Collection

Burdens and Economic Impacts of Medical Care SAQ

IC 269113 under ICR 202406-0935-002 · OMB 0935-0118.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0118 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 63 Burdens and Economic Impacts of Medical Care SAQ	Form and Instruction
63 Burdens and Economic Impacts of Medical Care SAQ Attachment 63 -- ESAQ.docx	Form and Instruction
63 Burdens and Economic Impacts of Medical Care SAQ Attachment 63 -- ESAQ.docx	Form and Instruction

IC Title:

Burdens and Economic Impacts of Medical Care SAQ

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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 and Instruction	63	Burdens and Economic Impacts of Medical Care SAQ	Attachment 63 -- ESAQ.docx		No		Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 16,170

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	8,085	8,085
Annual IC Time Burden (Hours)	1,348	1,348
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.