View Information Collection (IC)

View Information Collection (IC)

IC Title:	Diabetes Care SAQ	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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
Form and Instruction	Attachment 22	Attachment 22 -- HC Diabetes SAQ - Proxy	Attachment 22 HC Diabetes SAQ Proxy.pdf		Yes	Yes	Paper Only
Form and Instruction	Attachment 23	Attachment 23 -- HC Diabetes SAQ - Self	Attachment 23 HC Diabetes SAQ Self.pdf		Yes	Yes	Paper Only

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: 2,072	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	2,072	0	0	0	0	2,072
Annual IC Time Burden (Hours)	104	0	0	0	0	104
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.