Information Collection

Adult Heart and HeartLung Status 4 Criteria 2 Extension Justification Form Medical Urgency Data

IC 276072 under ICR 202506-0915-004 · OMB 0915-0157.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 145 Adult Heart and HeartLung Status 4 Criteria 2 Extension Justification Form Medical Urgency Data	Form
Form 145 Adult Heart and HeartLung Status 4 Criteria 2 Extension Justification Form Medical Urgency Data Adult Heart and HeartLung Status 4 Criteria 2 Extension Justification Form Medical Urgency Data	Form
145. Adult Heart and HeartLung Status 4 Criteria 2 Extension Justification Form Medical Urgency Data_Instructions.docx	Instruction
145. Adult Heart and HeartLung Status 4 Criteria 2 Extension Justification Form Medical Urgency Data_Instructions.docx	Instruction
145 Adult Heart and HeartLung Status 4 Criteria 2 Extension 145. Adult Heart and HeartLung Status 4 Criteria 2 Extension Justification Form Medical Urgency Data_Form.xlsx	Form
145 Adult Heart and HeartLung Status 4 Criteria 2 Extension 145. Adult Heart and HeartLung Status 4 Criteria 2 Extension Justification Form Medical Urgency Data_Form.xlsx	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

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	145				Yes	Yes	Fillable Fileable
Instruction					Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Privacy Act System of Records 09-15-0055

FR Citation: 87 FR 46967

Number of Respondents: 149

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	83	83
Annual IC Time Burden (Hours)	33	33
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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