Information Collection

Questionnaire

IC 201175 under ICR 201202-0923-001 · OMB 0923-0045.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0045 can be found here:

Documents and Forms

Document Name Document Type
Questionnaire Form
Questionnaire OMB Appendix F Questionnaire January 25 2012 (2).doc Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Questionnaire	OMB Appendix F Questionnaire January 25 2012 (2).doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title: Records of Persons Exposed or Potentially Exposed to Toxic or Hazardous Substances	FR Citation: 53 FR 30720

Number of Respondents: 2,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,500	2,500
Annual IC Time Burden (Hours)	1,042	1,042
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.