Information Collection

Primary Data Coordinator Form

IC 256997 under ICR 202512-0915-001 · OMB 0915-0184.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 17 Primary Data Coordinator Form	Form and Instruction
Form 17 Primary Data Coordinator Form Primary Data Coordinator Form	Form and Instruction
17 Primary Data Coordinator Form 17_Primary Data Coordinator Form_CLEAN.docx	Form and Instruction
17 Primary Data Coordinator Form 17_Primary Data Coordinator Form_CLEAN.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

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 and Instruction	17				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,032

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

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	93	40	53
Annual IC Time Burden (Hours)	40	33	7
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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