View Information Collection (IC)

View Information Collection (IC)

IC Title:	PHS Assignment Request Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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	14	PHS Assignment Reqest Form	Attachment 5C PHS Assignment Request Form.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: 3,354	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: 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	3,354	0	0	0	0	3,354
Annual IC Time Burden (Hours)	1,677	0	0	0	0	1,677
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment 5B PHS Assignment Request Instructions	Attachment 5B PHS Assignment Request Instructions.docx	01/25/2017

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