Information Collection

Adult Liver Status 1A Initial Justification and Extension Form

IC 276026 under ICR 202610-0906-001 · OMB 0906-0110.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 105 Adult Liver Status 1A Initial Justification and Extension Form Adult Liver Status 1A Initial Justification and Extension Form	Form
108. Adult Liver Status 1A Initial Justification and Extension Form_Instructions.docx	Instruction
105 Adult Liver Status 1A Initial Justification and Extensio 108. Adult Liver Status 1A Initial Justification and Extension Form_Form.xlsx	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

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
Instruction					Yes	Yes	Fillable Fileable
Form	105				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Privacy Act System of Records 09-15-0055

FR Citation: 87 FR 46967

Number of Respondents: 144

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: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	307	-21	328
Annual IC Time Burden (Hours)	175	-12	187
Annual IC Cost Burden (Dollars)	0	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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