OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Eligibility/Registration Form and Data Submission

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

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Eligibility/Registration Form and Data Submission
 
No Removed
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction Form # 1 Attachment A: Hospital Eligibility and Registration Form Attachment A - Eligibility and Registration Form - 3-1-22.docx Yes Yes Fillable Fileable

Health Consumer Health and Safety

 

340 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 0 0 0 -340 340 0
Annual IC Time Burden (Hours) 0 0 0 -17 17 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Attachment I -- Emails for Hospital SOPS Data Submission Attachment I -- Emails for Hospital SOPS Data Submission.doc 07/31/2013
Attachment J -- Screen Shots Hospital SOPS Forms Attachment J -- Screen Shots Hospital SOPS Forms.doc 07/31/2013
Attachment K -- HSOPS Survey Data File Specifications Attachment K -- HSOPS Survey Data File Specifications.docx 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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