Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Annual Hospital Interview Modified 598 1196 0 Form and Instruction 0920-0212 Annual Hospital Interview 2019
Annual Ambulatory Hospital Interview Removed 0 0 0 Form and Instruction 0920-0212 Att K - Ann Amb Hosp Inter
Initial Hospital Intake Questionnaire Modified 150 150 0 Form and Instruction 0920-0212 Initial Hospital Intake Questionnaire 2019
Prepare and Transmit EHR for Inpatient and Ambulatory Modified 796 796 0 Form and Instruction 0920-0212 EHR for Inpatient and Ambulatory (quarterly)
Prepare and transmit UB-04 or State File for Inpatient and Ambulatory Modified 4788 4788 0 Form and Instruction 0920-0212 UB-04 or State File for Inpatient and Ambulatory (monthly)
Recruitment Survey Presentation Modified 150 150 0 Form and Instruction 0920-0212 Recruitment Survey Presentation 2019
Total burden requested under this ICR: 6482 7080 0  
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