Information Collection

Liver Hepatocellular Carcinoma (HCC) MELD/PELD Score Exception Extension Form

IC 276039 under ICR 202610-0906-001 · OMB 0906-0110.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 115 Liver Hepatocellular Carcinoma (HCC) MELD/PELD Score Exception Extension Form Liver Hepatocellular Carcinoma (HCC) MELD/PELD Score Exception Extension Form	Form
118. Liver Hepatocellular Carcinoma HCC MELD PELD Exception Score Extension Form_Instructions.docx	Instruction
115 Liver Hepatocellular Carcinoma (HCC) MELD/PELD Score Exc 118. Liver Hepatocellular Carcinoma (HCC) MELDPELD Score Exception 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	115				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Privacy Act System of Records

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	4,153	-563	4,716
Annual IC Time Burden (Hours)	1,454	-197	1,651
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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