Information Collection

Visitors and Staff

IC 181800 under ICR 200708-0925-002 · OMB 0925-0458.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0458 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 3 Built-Adults Visitors and Staff	Form and Instruction
Form 4 Built-Peds Visitors and Staff	Form and Instruction
3 Built-Adults Built Environment Survey Adult.pdf	Form and Instruction
4 Built-Peds Built Environment Survey Peds.pdf	Form and Instruction

IC Title:

Visitors and Staff

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	3				Yes	Yes	Paper Only
Form and Instruction	4				Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 6,500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	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	6,500	0	0	0	0	0
Annual IC Time Burden (Hours)	1,105	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

table that charts IC Documents
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.

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