Information Collection

71.21 (c) Recordkeeping – medical records (AGE Logs)

IC 235072 under ICR 202204-0920-002 · OMB 0920-1260.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1260 can be found here:

Documents and Forms

Document Name Document Type
71.21 (c) Recordkeeping – medical records (AGE Logs) Form and Instruction
VSP AGE Log Att5b.AGELog.pdf Form and Instruction
VSP AGE Log Att5b.AGELog.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	71.21 (c) Recordkeeping – medical records (AGE Logs)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

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 and Instruction	NA	VSP AGE Log	Att5b.AGELog.pdf	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 250	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-250	250
Annual IC Time Burden (Hours)	-4	4
Annual IC Cost Burden (Dollars)	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.