Information Collection

Hospitalizations Form

IC 222646 under ICR 202607-0920-013 · OMB 0920-1175.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1175 Data Dictionary- Hospitalizations 03AUG2026 Hospitalizations Form	Form and Instruction
0920-1175 Data Dictionary- Hospitalizations 03AUG2026 Att4D Hospitalizations Form.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

0920-1175

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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	0920-1175			N/A	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 37

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	37	37
Annual IC Time Burden (Hours)	1,480	1,480
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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