Information Collection

Eligibility/Registration Form and Data Submission

IC 191667 under ICR 202512-0935-004 · OMB 0935-0162.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form # 1 Eligibility/Registration Form and Data Submission	Form and Instruction
Form Form # 1 Attachment A: Hospital Eligibility and Registration Form Eligibility/Registration Form and Data Submission	Form and Instruction
Form # 1 Attachment A: Hospital Eligibility and Registration Form Attachment A - Eligibility and Registration Form - 3-1-22.docx	Form and Instruction
Form # 1 Attachment A: Hospital Eligibility and Registration Form Attachment A - Eligibility and Registration Form - 3-1-22.docx	Form and Instruction
Attachment I -- Emails for Hospital SOPS Data Submission.doc Attachment I -- Emails for Hospital SOPS Data Submission	IC Document
Attachment I -- Emails for Hospital SOPS Data Submission.doc Attachment I -- Emails for Hospital SOPS Data Submission	IC Document
Attachment J -- Screen Shots Hospital SOPS Forms.doc Attachment J -- Screen Shots Hospital SOPS Forms	IC Document
Attachment J -- Screen Shots Hospital SOPS Forms.doc Attachment J -- Screen Shots Hospital SOPS Forms	IC Document
Attachment K -- HSOPS Survey Data File Specifications.docx Attachment K -- HSOPS Survey Data File Specifications	IC Document
Attachment K -- HSOPS Survey Data File Specifications.docx Attachment K -- HSOPS Survey Data File Specifications	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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	Form # 1				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 340

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: 0 %

table that charts list of burden
	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	-340	340
Annual IC Time Burden (Hours)	-17	17
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment I -- Emails for Hospital SOPS Data Submission		07/31/2013
Attachment J -- Screen Shots Hospital SOPS Forms		07/31/2013
Attachment K -- HSOPS Survey Data File Specifications		07/31/2013

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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