Information Collection

Food Record Form

IC 207195 under ICR 201306-0920-001 · OMB 0920-0982.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0982 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Food Record Form	Form
Food Record Form Att 12A_Food Record Form.docx	Form
Att 12B_Food Record Instructions.docx Att 12B_Food Record Instructions	IC Document

IC Title:

Food Record 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
Form	None	Food Record Form	Att 12A_Food Record Form.docx		Yes	No	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title: 09-20-0136, Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 252

Number of Respondents: 225

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	900	900
Annual IC Time Burden (Hours)	225	225
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att 12B_Food Record Instructions	Att 12B_Food Record Instructions.docx	06/04/2013

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