Information Collection

Nomination Form

IC 206920 under ICR 201404-0920-004 · OMB 0920-0976.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0976 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Nomination Form	Form
Nomination Form Attachment 3a Nomination Form_7 23 2013.docm	Form
Website Screenshots Attachment 6 Screenshots 7-24-2013.pdf	Form
Attachment 3b. Confirmation email_4 4 2013.docx Confirmation Email	IC Document

IC Title:

Nomination Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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	Nomination Form	Attachment 3a Nomination Form_7 23 2013.docm		Yes	Yes	Fillable Fileable
Form	none	Website Screenshots	Attachment 6 Screenshots 7-24-2013.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,735

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	1,735	1,735
Annual IC Time Burden (Hours)	868	868
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Confirmation Email	Attachment 3b. Confirmation email_4 4 2013.docx	05/08/2013

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