Information Collection

416-9

IC 7244 under ICR 201102-0925-008 · OMB 0925-0002.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0002 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
phs416-9.docm	Instruction
1 Form 416-1cont.docm	Form
2 Form 416-9 fp1.docm	Form
3 Form 416-9 fp3.docm	Form
4 Report 416-9-Inclusion enrollment_report.docm	Form
4 Table 416-9-Targeted_Planned enrollment_table.docm	Form
2 Form 416-9 fp2.doc	Form

IC Title:

416-9

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			phs416-9.docm	Yes	Yes	Paper Only
Form	1	Form	416-1cont.docm	Yes	Yes	Paper Only
Form	2	Form	416-9 fp1.docm	Yes	Yes	Paper Only
Form	3	Form	416-9 fp3.docm	Yes	Yes	Paper Only
Form	4	Report	416-9-Inclusion enrollment_report.docm	Yes	Yes	Paper Only
Form	4	Table	416-9-Targeted_Planned enrollment_table.docm	Yes	Yes	Paper Only
Form	2	Form	416-9 fp2.doc	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,832

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	1,832	1,832
Annual IC Time Burden (Hours)	27,480	27,480
Annual IC Cost Burden (Dollars)	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.