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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
416-1
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Required to Obtain or Retain Benefits
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
19
Attachment 7B PHS 416-1 Face Page 1
Attachment 7B PHS 416-1 Face Page 1.docx
Yes
Yes
Fillable Fileable
Instruction
Attachment 7A PHS 416-1 Instructions.docx
Yes
Yes
Paper Only
Form and Instruction
20
Attachment 7C PHS 416-1 Face Page 2
Attachment 7C PHS 416-1 Face Page 2.docx
Yes
Yes
Fillable Fileable
Form and Instruction
21
Attachment 7D PHS 416-1 Face Page 3
Attachment 7D PHS 416-1 Face Page 3.docx
Yes
Yes
Fillable Fileable
Form and Instruction
22
Attachment 7E PHS 416-1 Face Page 4
Attachment 7E PHS 416-1 Face Page 4.docx
Yes
Yes
Fillable Fileable
Form and Instruction
23
Attachment 7F PHS 416-1 Checklist Form Page
Attachment 7F PHS 416-1 Checklist Form Page.docx
Yes
Yes
Fillable Fileable
Form and Instruction
24
Attachment 7G PHS 416-1 Continuation Page
Attachment 7G PHS 416-1 Continuation Page.docx
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:
29
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
29
0
0
0
0
29
Annual IC Time Burden (Hours)
290
0
0
0
0
290
Annual IC Cost Burden (Dollars)
0
0
0
0
0
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.