Information Collection

500 or more affected Individuals

IC 190796 under ICR 201211-0945-001 · OMB 0945-0001.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0945-0001 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

500 or more affected Individuals

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 45 CFR 160

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

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 56

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	56	56
Annual IC Time Burden (Hours)	2,464	2,464
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.