View Information Collection (IC)

View Information Collection (IC)

IC Title:	Death Notification Referral-Imminent	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Death Notification Referral-Imminent	Death Notification Referral-Imminent	Death Notification Referral - Imminent.pdf		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 58	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 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	9,744	0	0	9,744	0	0
Annual IC Time Burden (Hours)	4,872	0	0	4,872	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Death Referral, Imminent, and Eligible Instructions	Death Referral, Imminent, and Eligible Instructions.pdf	09/14/2010

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.