Information Collection

ADR Submission

IC 273679 under ICR 202501-0906-002 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
OPAIS ADR submission slides .pdf	Instruction
OPAIS ADR submission slides .pdf	Instruction
Burden Statement to include in OPAIS.docx Burden Statement to Include in OPAIS	IC Document
Burden Statement to include in OPAIS.docx Burden Statement to Include in OPAIS	IC Document

IC Title:

ADR Submission

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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
Instruction					Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 15

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	15	15
Annual IC Time Burden (Hours)	38	38
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Burden Statement to Include in OPAIS		01/16/2025

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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