Information Collection

Primary Team/ EIP Team Data Collection Form

IC 196207 under ICR 201304-0920-003 · OMB 0920-0852.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0852 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0852 Primary Team/ EIP Team Data Collection Form	Form and Instruction
0920-0852 AttachmentC_0920-0852_OMBApprovedDataCollectionForm AttachmentC_0920-0852_OMBApprovedDataCollectionForm_FINAL_20130205.docx	Form and Instruction
AttachmentF_0920-0852_SupplementalInformationOnly_FINAL_20121108.docx AttachmentF_0920-0852_SupplementalInformationOnly	IC Document

IC Title:

Primary Team/ EIP Team Data Collection 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	0920-0852	AttachmentC_0920-0852_OMBApprovedDataCollectionForm	AttachmentC_0920-0852_OMBApprovedDataCollectionForm_FINAL_20130205.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 500

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
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	37,500	1,000	36,500
Annual IC Time Burden (Hours)	7,500	200	7,300
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
AttachmentF_0920-0852_SupplementalInformationOnly	AttachmentF_0920-0852_SupplementalInformationOnly_FINAL_20121108.docx	04/02/2013

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