Information Collection

Unanticipated Problem or Serious or Continuing Noncompliance Application (Attachment B52)

IC 265724 under ICR 202411-0925-001 · OMB 0925-0753.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Unanticipated Problem or Serious or Continuing Noncompliance Application (Attachment B52)	Form
Form 1 Unanticipated Problem or Serious or Continuing Noncompliance Application Unanticipated Problem or Serious or Continuing Noncompliance Application (Attachment B52)	Form
1 Unanticipated Problem or Serious or Continuing Noncompli Attachment B52_Unanticipated_Problem_Noncompliance_Application_01AUG2023.docx	Form
1 Unanticipated Problem or Serious or Continuing Noncompli Attachment B52_Unanticipated_Problem_Noncompliance_Application_01AUG2023.docx	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 20

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	Previously Approved
Annual Number of Responses for this IC	20	20
Annual IC Time Burden (Hours)	10	10
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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