Information Collection

Follow-up to Request for Clinical & Medical Treatment Records

IC 214198 under ICR 202608-3095-001 · OMB 3095-0039.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form NA For 13177 Check the Status of a Clinical & Medical & Treatment Records Request Follow-up to Request for Clinical & Medical Treatment Records	Form and Instruction
NA For 13177 Check the Status of a Clinical & Medical & Treatment Rec NA13177_06_2017_3095-0039.pdf www.archives.gov/forms/st-louis/clinical-followup.html	Form and Instruction
Explanation_June_2023.docx Explanation_June_2023	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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	NA For 13177			https://www.archives.gov/forms/st-louis/clinical-followup.html	Yes	Yes	Fillable Fileable

Line of Business: Education

Subfunction: Cultural and Historic Preservation

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	1	1
Annual IC Time Burden (Hours)	0	0
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Explanation_June_2023		06/15/2023

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].