Information Collection

Data Files Submission

IC 237061 under ICR 202602-0935-001 · OMB 0935-0245.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 4 Data Files Submission Data Files Submission	Form and Instruction
4 Data Files Submission Attachment E Data Submission Emails_FINAL_11.26 .docx	Form and Instruction
60 Day FRN.pdf 60 Day Federal Register Notice	IC Document

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	4				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 13

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	52	0	52
Annual IC Time Burden (Hours)	52	0	52
Annual IC Cost Burden (Dollars)	5,182	5,182	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
60 Day Federal Register Notice		07/23/2019

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

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