Information Collection

57.404 Outpatient Procedure Component - SSI Denominators

IC 228153 under ICR 202412-0920-019 · OMB 0920-0666.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0666 can be found here:

Documents and Forms

Document Name Document Type
Form 57.404 57.404 Outpatient Procedure Component - SSI Denominators Form
57.404 Outpatient Procedure Component - SSI Denominators 57.404 Outpatient SSI Denominator-Clean Version.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	57.404 Outpatient Procedure Component - SSI Denominators	Agency IC Tracking Number:	0920-0666

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	57.404	Outpatient Procedure Component - SSI Denominators	57.404 Outpatient SSI Denominator-Clean Version.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 300	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	30,000	30,000
Annual IC Time Burden (Hours)	11,500	11,500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.