Information Collection

484.100(a) - new agencies

IC 217410 under ICR 202509-0938-018 · OMB 0938-1299.

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Information Collection (IC) Details

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IC Title:	484.100(a) - new agencies	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 484.100(a)

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: 11,200	Number of Respondents for Small Entity: 388

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	11,200	10,812	388
Annual IC Time Burden (Hours)	930	542	388
Annual IC Cost Burden (Dollars)	0	0	0

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