Information Collection

Establishment Questionnaire

IC 182460 under ICR 201303-0935-001 · OMB 0935-0110.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0110 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form #2 Establishment Questionnaire	Form and Instruction
Form #2 Attachment B -- Establishment Questionnaire -- Revised ATTACHMENT B -- Establishment Questionnaire -- Revised.pdf	Form and Instruction
ATTACHMENT B -- Establishment Questionnaire -- Currently Approved.pdf ATTACHMENT B -- Establishment Questionnaire -- Currently Approved	IC Document

IC Title:

Establishment Questionnaire

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	Form #2	Attachment B -- Establishment Questionnaire -- Revised	ATTACHMENT B -- Establishment Questionnaire -- Revised.pdf		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 25,839

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions, Farms

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	25,839	25,839
Annual IC Time Burden (Hours)	9,819	9,819
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
ATTACHMENT B -- Establishment Questionnaire -- Currently Approved	ATTACHMENT B -- Establishment Questionnaire -- Currently Approved.pdf	03/21/2013

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.