Information Collection

PHS Assignment Request Form

IC 202959 under ICR 202408-0925-001 · OMB 0925-0001.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 PHS Assignment Request Form	Form
Form 1 Application PHS Assignment Request Form	Form
Form 2 Application PHS Assignment Request Form	Form
1 Application Attachment 5B_PHS Assignment Request Form_Instructions_FORMS-I.docx	Form
1 Application Attachment 5B_PHS Assignment Request Form_Instructions_FORMS-I.docx	Form
2 Application Attachment 5C_PHS_AssignmentRequestForm_4_0-V4.0_FORMS-I.pdf	Form
2 Application Attachment 5C_PHS_AssignmentRequestForm_4_0-V4.0_FORMS-I.pdf	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	1				Yes	Yes	Fillable Fileable
Form	2				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 37,120

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	37,120	37,120
Annual IC Time Burden (Hours)	18,560	18,560
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.

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