Information Collection

Certification and Deferment Form

IC 200079 under ICR 201211-0925-010 · OMB 0925-0299.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0299 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Certification and Deferment Form	Form and Instruction
1 Certification UGSP-Certification Form.pdf	Form and Instruction
2 Deferment Form UGSP-Deferment Form.pdf	Form and Instruction

IC Title:

Certification and Deferment Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	1	Certification	UGSP-Certification Form.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	2	Deferment Form	UGSP-Deferment Form.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 430

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	430	430
Annual IC Time Burden (Hours)	108	108
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.