Information Collection

57.404 Outpatient Procedure Component - SSI Denominators

IC 228153 under ICR 202603-0920-006 · OMB 0920-0666.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 57.404 Outpatient Procedure Component - SSI Denominators 57.404 Outpatient Procedure Component - SSI Denominators	Form
57.404 Outpatient Procedure Component - SSI Denominators 57.404 OPC DenomProc Clean Version.docx	Form

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	57.404				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 300

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	30,000	0	30,000
Annual IC Time Burden (Hours)	11,000	-500	11,500
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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