Information Collection

Questionnaire Materials

IC 206836 under ICR 201312-0923-001 · OMB 0923-0049.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att3.13_QuestionnaireMaterial.docx	Other-WORD

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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			Att3.13_QuestionnaireMaterial.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: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	250	250
Annual IC Time Burden (Hours)	188	188
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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