Information Collection

Epidemiological Research Request -- State and Local Government

IC 9755 under ICR 201010-0960-004 · OMB 0960-0701.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0701 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Epidemiological Research Review Information, Application and Confidentiality Agreement - Revised Version.pdf www.socialsecurity.gov/	Other-Internet Screens
Epidemiological Research Review Information, Application and Confidentiality Agreement - Current Version.pdf Current Epidemiological Research Review Internet Screens	IC Document

IC Title:

Epidemiological Research Request -- State and Local Government

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 401.165

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
Other-Internet Screens			Epidemiological Research Review Information, Application and Confidentiality Agreement - Revised Version.pdf	http://www.socialsecurity.gov/	Yes	Yes	Fillable Fileable Signable

Line of Business: General Science and Innovation

Subfunction: Scientific and Technological Research and Innovation

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 15

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	15	0	15
Annual IC Time Burden (Hours)	30	0	30
Annual IC Cost Burden (Dollars)	54,975	54,975	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current Epidemiological Research Review Internet Screens	Epidemiological Research Review Information, Application and Confidentiality Agreement - Current Version.pdf	12/23/2010

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