Information Collection

403.736(a)(b)

IC 237427 under ICR 202604-0938-005 · OMB 0938-1367.

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Information Collection (IC) Details

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IC Title:	403.736(a)(b)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 403.736(a)(b)

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	603	16
Annual IC Time Burden (Hours)	619	563	56
Annual IC Cost Burden (Dollars)	0	0	0

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