Information Collection

Initial Results Information of Voluntary and Non-regulated Submissions

IC 239363 under ICR 202512-0925-004 · OMB 0925-0586.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2 Results Information Submission Data Entry Forms Initial Results Information of Voluntary and Non-regulated Submissions	Form and Instruction
Form 2 Results Information Submission Data Entry Forms Initial Results Information of Voluntary and Non-regulated Submissions	Form and Instruction
2 Results Information Submission Data Entry Forms Attachment 5 - Results PRS Forms.pdf	Form and Instruction
2 Results Information Submission Data Entry Forms Attachment 5 - Results PRS Forms.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

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	2				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,100

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: 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	2,100	700	1,400
Annual IC Time Burden (Hours)	84,000	28,000	56,000
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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