Information Collection Request

User Access Request Form for EPIC System Portal (ESP)

ICR 202507-1117-002 · OMB unassigned · Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form OMB #1117-0NEW ESP User Access Request Form Form and Instruction New Available
Form OMB #1117-0NEW User Access Request Form for EPIC System Portal (ESP) Form and Instruction New Repair queued
Supporting Statement A - User Access Request Form for ESP.docx Supporting Statement A Uploaded 2026-01-09 Available
Supporting Statement A - User Access Request Form for ESP.docx Supporting Statement A Uploaded 2026-01-09 Repair queued
New User Request Form.pdf Supplementary Document Uploaded 2025-07-22 Available
New User Request Form.pdf Supplementary Document Uploaded 2025-07-22 Available

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
276653 User Access Request Form for EPIC System Portal (ESP) Form and Instruction NewESP User Access Request Form
276653 User Access Request Form for EPIC System Portal (ESP) Form and Instruction New

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
03/31/2029 36 Months From Approved
1,000 0 0
116 0 0
4,000 0 0





Reginfo record details
1
table that charts list of burden
IC Title Form No. Form Name
User Access Request Form for EPIC System Portal (ESP) OMB #1117-0NEW

table that charts list of burden
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 1,000 0 0 1,000 0 0
Annual Time Burden (Hours) 116 0 0 116 0 0
Annual Cost Burden (Dollars) 4,000 0 0 4,000 0 0


Reginfo record details
  No