Information Collection

Hospital Discharge Injury Indicators

IC 249952 under ICR 202506-0920-006 · OMB 0920-1365.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1365 Hospital Discharge Injury Indicators	Form
Form 0920-1365 HosDischargeInjuryIndicator_CoreSIPP Hospital Discharge Injury Indicators	Form
0920-1365 HosDischargeInjuryIndicator_CoreSIPP Att J_HosDischargeInjuryIndicator.xlsx	Form
0920-1365 HosDischargeInjuryIndicator_CoreSIPP Att J_HosDischargeInjuryIndicator.xlsx	Form

IC Title:

Agency IC Tracking Number:

0920-1365

Is this a Common Form? No

IC Status: Modified

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
Form	0920-1365				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 26

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	26	3	23
Annual IC Time Burden (Hours)	130	15	115
Annual IC Cost Burden (Dollars)	0	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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