Information Collection

Emergency Departments Paper and Pencil Questionnaire

IC 183189 under ICR 200712-0920-011 · OMB 0920-0775.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0775 can be found here:

Documents and Forms

Document Name Document Type
A16_ Emergency Medicine_Paper and Pencil.doc Other-WORD

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Emergency Departments Paper and Pencil Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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
Other-WORD			A16_ Emergency Medicine_Paper and Pencil.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 24	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
Annual Number of Responses for this IC	24	24
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.