Information Collection

57.121 Denominators for Procedure

IC 183564 under ICR 202603-0920-006 · OMB 0920-0666.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 57.121 Denominator for Procedure 57.121 Denominators for Procedure	Form and Instruction
57.121 Denominator for Procedure 57.121 DenomProc Clean Version.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

0920-0666

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	57.121			NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,800

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
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	45,600	0	45,600
Annual IC Time Burden (Hours)	9,880	-760	10,640
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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