Information Collection

Minnesota Participant Questionnaire

IC 201463 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⚠️ Notice: This information collection may be referencing outdated material.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 Participant Questionnaire	Form
Minnesota Participant Questionnaire Att5e_MN_StdyPartQs.doc	Form

IC Title:

Minnesota Participant Questionnaire

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 Participant Questionnaire	Att5e_MN_StdyPartQs.doc		Yes	Yes	Fillable Fileable

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: 100 %

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)	125	125
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.