Nomination Form

Million Hearts Hypertension Control Challenge

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0976 can be found here:

Documents and Forms

Document Name Document Type
Nomination Form Form
Nomination Form Attachment 3a Nomination Form_7 23 2013.docm Form
Website Screenshots Attachment 6 Screenshots 7-24-2013.pdf Form
Attachment 3b. Confirmation email_4 4 2013.docx Confirmation Email IC Document

Information Collection (IC) Details

IC Title:	Nomination Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Nomination Form	Attachment 3a Nomination Form_7 23 2013.docm		Yes	Yes	Fillable Fileable
Form	none	Website Screenshots	Attachment 6 Screenshots 7-24-2013.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,735	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,735	1,735
Annual IC Time Burden (Hours)	868	868
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Confirmation Email	Attachment 3b. Confirmation email_4 4 2013.docx	05/08/2013

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