Information Collection

Year 3 (IC 1 & IC 3 - New Facilities and IC 2 & IC 4 - All Facilities)

IC 248123 under ICR 202506-0938-010 · OMB 0938-1402.

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Information Collection (IC) Details

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IC Title:	Year 3 (IC 1 & IC 3 - New Facilities and IC 2 & IC 4 - All Facilities)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 483.460(a)(4) 42 CFR 483.460(a)(4)(ii)(iii)(iv)

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: 5,523	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, 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	5,523	-249	5,772
Annual IC Time Burden (Hours)	24,053	6,737	17,316
Annual IC Cost Burden (Dollars)	0	0	0

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