Information Collection

2012 Healthy New Year Video Contest Submission Form

IC 200729 under ICR 201201-0990-002 · OMB 0990-0386.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
0990-Emergency_2012 Healthy New Year Video Challenge_Contest_Submission Form__010811[1].doc	Other-instrument
0990-Healthy New Year Challenge_OMB01092012_Emergency Justification Letter[1].doc Emergency Justification letter	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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
Other-instrument			0990-Emergency_2012 Healthy New Year Video Challenge_Contest_Submission Form__010811[1].doc		No	No	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 300

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
Annual Number of Responses for this IC	300	300
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Emergency Justification letter	0990-Healthy New Year Challenge_OMB01092012_Emergency Justification Letter[1].doc	01/10/2012

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