Information Collection

Attachment D: Hospital Information Submission Form

IC 235458 under ICR 202601-0935-001 · OMB 0935-0243.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 3 Attachment D: Hospital Information Submission Form	Form and Instruction
Form 3 Attachment D- Hospital Information Submission Form Attachment D: Hospital Information Submission Form	Form and Instruction
3 Attachment D- Hospital Information Submission Form Attachment D Hospital Information Submission Form.pdf	Form and Instruction
3 Attachment D- Hospital Information Submission Form Attachment D Hospital Information Submission Form.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	3				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50

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	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	50	0	-250	300
Annual IC Time Burden (Hours)	4	0	-21	25
Annual IC Cost Burden (Dollars)	530	530	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.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].