Information Collection

403.724(a)(2) & (a)(3)

IC 237419 under ICR 202604-0938-005 · OMB 0938-1367.

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Information Collection (IC) Details

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IC Title:	403.724(a)(2) & (a)(3)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 403.724(a)(2) & (a)(3)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 14	Number of Respondents for Small Entity: 14

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	619	0	619
Annual IC Time Burden (Hours)	1,103	948	155
Annual IC Cost Burden (Dollars)	0	0	0

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