Information Collection

Safe to Sleep National Champions Tracking and Feedback Form

IC 214192 under ICR 201403-0925-009 · OMB 0925-0701.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0701 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Safe to Sleep National Champions Tracking and Feedback Form	Form and Instruction
1 National Champions Tracking and Feedback Screenshots Attachment 3_0925-0701_National Champions Tracking and Feedback Form_Screenshots_rev_12-5-14.pdf	Form and Instruction
0925-0701_GC Form_National Champions Tracking and Feedback Form_Indiv-HH.doc Generic Clearance Form National Champions	IC Document
0925-0701_Sub-study Memo_National Champions Tracking and Feedback Form_Indiv-HH_12-9-14.doc Cover Memo National Champions	IC Document

IC Title:

Safe to Sleep National Champions Tracking and Feedback Form

Agency IC Tracking Number:

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	1	National Champions Tracking and Feedback Screenshots	Attachment 3_0925-0701_National Champions Tracking and Feedback Form_Screenshots_rev_12-5-14.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	250	250
Annual IC Time Burden (Hours)	125	125
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Generic Clearance Form National Champions	0925-0701_GC Form_National Champions Tracking and Feedback Form_Indiv-HH.doc	12/09/2014
Cover Memo National Champions	0925-0701_Sub-study Memo_National Champions Tracking and Feedback Form_Indiv-HH_12-9-14.doc	12/11/2014

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