Information Collection

ICR Req's in HSQ-110, Acquisition, Protection and Disclosure of PRO Information and Supporting Regulations in 42 CFR 476.104, 476.105, 476.116, 476.134

IC 43656 under ICR 202511-0938-016 · OMB 0938-0426.

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Information Collection (IC) Details

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IC Title:	ICR Req's in HSQ-110, Acquisition, Protection and Disclosure of PRO Information and Supporting Regulations in 42 CFR 476.104, 476.105, 476.116, 476.134	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 480.116 42 CFR 480.134 42 CFR 480.105 42 CFR 480.104

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: 2	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	53,850	0	53,850
Annual IC Time Burden (Hours)	521,599	117,391	404,208
Annual IC Cost Burden (Dollars)	0	0	0

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