Information Collection

Supplemental Investigator Data Form

IC 190376 under ICR 200909-0925-003 · OMB 0925-0613.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0613 can be found here:

Documents and Forms

Document Name Document Type
Form 2 Supplemental Investigator Data Form Form and Instruction
2 Supplemental Investigator Data Form Attachment 2_Supplemental Investigator_Final 053109.doc Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Supplemental Investigator Data Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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	2	Supplemental Investigator Data Form	Attachment 2_Supplemental Investigator_Final 053109.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 17,128	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	17,128	17,128
Annual IC Time Burden (Hours)	2,855	2,855
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.