Information Collection

Office Based Providers Form

IC 191103 under ICR 202603-0935-001 · OMB 0935-0118.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 57 Office Based Provider Form Office Based Providers Form	Form and Instruction
57 Office Based Provider Form Attachment 57 -- Office Based Provider Event Form.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	57				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 8,074

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: 0 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	28,905	2,865	26,040
Annual IC Time Burden (Hours)	1,445	143	1,302
Annual IC Cost Burden (Dollars)	63,320	63,320	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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