Information Collection

Diabetes Care SAQ

IC 191099 under ICR 202603-0935-001 · OMB 0935-0118.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 50 Diabetes Care SAQ Diabetes Care SAQ	Form and Instruction
50 Diabetes Care SAQ Attachment 50 -- Diabetes Care SAQ.pdf	Form and Instruction

IC Title:

Diabetes Care SAQ

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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	50				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,398

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	-1,398	1,398
Annual IC Time Burden (Hours)	-70	70
Annual IC Cost Burden (Dollars)	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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