Information Collection

Reporting of Test Results (during study)

IC 211021 under ICR 201403-0920-017 · OMB 0920-1018.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Reporting of Test Results (during study)	Form and Instruction
Reporting Home Test Results Reporting of Home Test Results_Screenshot.docx	Form and Instruction
Att 3e Reporting of Self-Test Results.docx Reporting Self Test	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 and Instruction	none	Reporting Home Test Results	Reporting of Home Test Results_Screenshot.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,600

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	4,800	4,800
Annual IC Time Burden (Hours)	400	400
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Reporting Self Test	Att 3e Reporting of Self-Test Results.docx	03/27/2014

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