Information Collection

Epidemiological Research Request -- State and Local Government

IC 9755 under ICR 201308-0960-013 · OMB 0960-0701.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Current Epidemiological Research Review Information Application and Confidentiality Agreement.pdf www.ssa.gov/policy/about/epidemiology.html	Other-Internet Screens
Previously Approved Epidemiological Research Review Information, Application and Confidentiality Agreement.pdf Previously Approved Epidemiological Research Review Internet Screens	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 401.165

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-Internet Screens			Current Epidemiological Research Review Information Application and Confidentiality Agreement.pdf	http://www.ssa.gov/policy/about/epidemiology.html	Yes	Yes	Fillable Fileable Signable

Line of Business: General Science and Innovation

Subfunction: Scientific and Technological Research and Innovation

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 15

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	15	0	15
Annual IC Time Burden (Hours)	30	0	30
Annual IC Cost Burden (Dollars)	52,500	-2,475	54,975

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Previously Approved Epidemiological Research Review Internet Screens	Previously Approved Epidemiological Research Review Information, Application and Confidentiality Agreement.pdf	10/23/2013

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