Information Collection

Interested Employer - Pilot Employer Application Form

IC 208006 under ICR 201308-0920-001 · OMB 0920-0989.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Interested Employer - Pilot Employer Application Form	Form
Pilot Employer Application Form Attachment I-2_Screen Shots Pilot Employer Application Form_6-27-13.doc	Form
Attachment I-1_Pilot Employer Application Form_6-25-13.doc Pilot Employer Application Form	IC Document

IC Title:

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	Pilot Employer Application Form	Attachment I-2_Screen Shots Pilot Employer Application Form_6-27-13.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title: 09-20-0160 Records of Subjects in Health Promotion and Education Studies

FR Citation: 51 FR 42484

Number of Respondents: 400

Number of Respondents for Small Entity: 400

Affected Public: Private Sector

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

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	400	400
Annual IC Time Burden (Hours)	33	33
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Pilot Employer Application Form	Attachment I-1_Pilot Employer Application Form_6-25-13.doc	07/25/2013

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