Information Collection

Adult Heart and HeartLung Status 1-6 Justification Form Demographic Data

IC 276050 under ICR 202610-0906-001 · OMB 0906-0110.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 126 Adult Heart and HeartLung Status 1-6 Justification Form Demographic Data Adult Heart and HeartLung Status 1-6 Justification Form Demographic Data	Form
129. Adult Heart and HeartLung Status 1-6 Justification Form Demographic Data_Instructions.docx	Instruction
126 Adult Heart and HeartLung Status 1-6 Justification Form 129. Adult Heart and HeartLung Status 1-6 Justification Form Demographic Data_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
Form	126				Yes	Yes	Fillable Fileable
Instruction					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: 149

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	24,074	3,843	20,231
Annual IC Time Burden (Hours)	7,704	1,230	6,474
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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