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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
57.204 Healthcare Worker Demographic Data
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
Other-WORD
57.204_HCWDemographicData_BLANK.docx
Yes
Yes
Fillable Printable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Public Health Monitoring
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
100
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Not-for-profit institutions
Percentage of Respondents Reporting Electronically:
0 %
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
100
0
-119,900
0
0
120,000
Annual IC Time Burden (Hours)
6,667
0
-33,333
0
0
40,000
Annual IC Cost Burden (Dollars)
264,600
0
264,600
0
0
0
Documents for IC
Title
Document
Date Uploaded
6_HPS_toi
6_HPS_toi.pdf
12/05/2011
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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