Information Collection

FY13 Pilot – Completion of Sections 1 and 3 – Full Service Facility Type

IC 204849 under ICR 201211-0910-005 · OMB 0910-0744.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0910-0744 can be found here:

Documents and Forms

Document Name Document Type
DATA COLLECTION FORM FOODBORNE ILLNESS 5-8-13.doc Other-SURVEY
MARKING INSTRUCTIONS 5-8-13.doc Other-Survey

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	FY13 Pilot â Completion of Sections 1 and 3 â Full Service Facility Type	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 21 CFR 5.10(a)(2)and(4)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-SURVEY			DATA COLLECTION FORM FOODBORNE ILLNESS 5-8-13.doc		No		Paper Only
Other-Survey			MARKING INSTRUCTIONS 5-8-13.doc		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 44	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	44	44
Annual IC Time Burden (Hours)	77	77
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.