Information Collection

Medication Form

IC 206834 under ICR 201305-0923-001 · OMB 0923-0049.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0923-0049 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att3.10_MedicationForm.docx	Other-WORD
Att3.6_ReminderTelScript.docx Att3	IC Document

IC Title:

Medication Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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
Other-WORD			Att3.10_MedicationForm.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title: 09-19-0001 Records of Persons Exposed or Potentially Exposed to Toxic or Hazardous Substances

FR Citation: 53 FR 30720

Number of Respondents: 250

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	250	250
Annual IC Time Burden (Hours)	12	12
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att3	Att3.6_ReminderTelScript.docx	04/29/2013

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