Serious Medical Procedure (SMR) Form - Care provider program staff

Serious Medical Procedure (SMR) Request Form

Documents and Forms

Document Name Document Type
Form 1 Serious Medical Procedure (SMR) Form - Care provider program staff Form
1 Serious Medical Procedure (SMR) Request Form SMR Form_Clean.docx Form
1 Serious Medical Procedure (SMR) Request Form SMR Form_Clean.docx Form

Information Collection (IC) Details

IC Title:	Serious Medical Procedure (SMR) Form - Care provider program staff	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	1	Serious Medical Procedure (SMR) Request Form	SMR Form_Clean.docx		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title: ORR Division of Children's Services Records	FR Citation: 81 FR 46682

Number of Respondents: 250	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 Agency Discretion	Previously Approved
Annual Number of Responses for this IC	115	-80	195
Annual IC Time Burden (Hours)	17	-14	31
Annual IC Cost Burden (Dollars)	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.