Information Collection

Test-level Data

IC 204799 under ICR 201301-0920-006 · OMB 0920-0959.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Test-level Data	Form and Instruction
Att4 Test Level Data Variables.docx	Instruction
Att4.1 HBV- HEPTLC Data Collection Template Att4.1 HBV- HEPTLC Data Collection Template.pdf	Form and Instruction
Att4.2 HCV- HEPTLC Data Collection Template Att4.2 HCV- HEPTLC Data Collection Template.pdf	Form and Instruction
Att4.3 ScreenShot - HEPTLC Data Collection HBV_HCV Att4.3 ScreenShot - HEPTLC Data Collection HBV_HCV.pdf	Form and Instruction

IC Title:

Test-level Data

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	none	Att4.1 HBV- HEPTLC Data Collection Template	Att4.1 HBV- HEPTLC Data Collection Template.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	none	Att4.2 HCV- HEPTLC Data Collection Template	Att4.2 HCV- HEPTLC Data Collection Template.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	none	Att4.3 ScreenShot - HEPTLC Data Collection HBV_HCV	Att4.3 ScreenShot - HEPTLC Data Collection HBV_HCV.pdf	Yes	Yes	Fillable Fileable
Instruction			Att4 Test Level Data Variables.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 40

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	480	480
Annual IC Time Burden (Hours)	5,760	5,760
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.