Information Collection

42 CFR 494.30(b)(3) and 494.40 (b)b2)(ii)(c)

IC 209390 under ICR 202504-0938-015 · OMB 0938-0386.

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Information Collection (IC) Details

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IC Title:	42 CFR 494.30(b)(3) and 494.40 (b)b2)(ii)(c)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 494.40(b)(2)(ii)(C) 42 CFR 494.40(b)(2)(ii)(C) 42 CFR 494.30(b)(3)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 160	Number of Respondents for Small Entity: 7

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	160	-4	164
Annual IC Time Burden (Hours)	14	0	14
Annual IC Cost Burden (Dollars)	0	0	0

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