Information Collection

Home Health Care Providers Event Form

IC 191101 under ICR 202603-0935-001 · OMB 0935-0118.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 55 Home Healthcare for Healthcare Providers Event Form Home Health Care Providers Event Form	Form and Instruction
Form 56 Home Healthcare for Non-healthcare Providers Home Health Care Providers Event Form	Form and Instruction
55 Home Healthcare for Healthcare Providers Event Form Attachment 55 -- Home Healthcare for Healthcare Providers Event Form.pdf	Form and Instruction
56 Home Healthcare for Non-healthcare Providers Attachment 56 -- Home Healthcare for Non-healthcare Providers.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	55				Yes	Yes	Fillable Fileable
Form and Instruction	56				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 505

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
	Requested	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,858	158	0	2,700
Annual IC Time Burden (Hours)	143	0	8	135
Annual IC Cost Burden (Dollars)	6,266	0	6,266	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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