Information Collection

Minnesota Consent

IC 201461 under ICR 201203-0923-001 · OMB 0923-0044.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0044 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Minnesota Consent	Form
Minnesota Consent Att5c_MN_Consent_2.15.12.docx	Form

IC Title:

Minnesota Consent

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
Form	none	Minnesota Consent	Att5c_MN_Consent_2.15.12.docx		No	No	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 250

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	250	250
Annual IC Time Burden (Hours)	13	13
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.