Information Collection

Requests For Health Assessments -- 42 Cfr Part 90

IC 111119 under ICR 199402-0923-001 · OMB 0923-0002.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0002 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	REQUESTS FOR HEALTH ASSESSMENTS -- 42 CFR PART 90	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

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

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 60	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	60	30	30
Annual IC Time Burden (Hours)	30	15	15
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded

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