Information Collection

Participants

IC 7266 under ICR 201101-0925-009 · OMB 0925-0281.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0281 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Clinic Examination Participants	Form and Instruction
Form 2 SEMI-ANNUAL FOLLOW-UP FORM Participants	Form and Instruction
1 Clinic Examination Attach #7 .docx	Form and Instruction
2 SEMI-ANNUAL FOLLOW-UP FORM Attach #8.pdf	Form and Instruction

IC Title:

Participants

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	1				Yes	Yes	Paper Only
Form and Instruction	2				Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10,933

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	32,799	20,807	11,992
Annual IC Time Burden (Hours)	20,221	17,344	2,877
Annual IC Cost Burden (Dollars)	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.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].