Information Collection

CIS Email Intake Form (Appendix 2)

IC 203805 under ICR 201208-0925-003 · OMB 0925-0208.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0208 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 7 CIS Email Intake Form (Appendix 2)	Form and Instruction
7 CIS Email Intake Form Appendix 2 Email Intake Form.docx	Form and Instruction

IC Title:

CIS Email Intake Form (Appendix 2)

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 and Instruction	7	CIS Email Intake Form	Appendix 2 Email Intake Form.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: Records of Participants in Programs and Respondents in Surveys Used to Evaluate Programs of the Public Health Service, HHS/PHS/NIH/OD

FR Citation: 67 FR 60743

Number of Respondents: 1,000

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	1,000	1,000
Annual IC Time Burden (Hours)	33	33
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.