Information Collection

Pulling and Refiling Medical Record Forms - CHC Provider and Staff

IC 213885 under ICR 201902-0920-021 · OMB 0920-0234.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0234 can be found here:

Documents and Forms

Document Name Document Type
Att I-2018-2019 PRF Burden Abstract.docx Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Pulling and Refiling Medical Record Forms - CHC Provider and Staff	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			Att I-2018-2019 PRF Burden Abstract.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: 09-20--0167 Health Resources Utilization Statistics	FR Citation: 49 FR 37697

Number of Respondents: 348	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	10,440	3,420	7,020
Annual IC Time Burden (Hours)	174	57	117
Annual IC Cost Burden (Dollars)	5,638	5,638	0

Documents for IC

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.