Information Collection

Questionnaire - Covered Entity Administrator or Privacy Officer(s)

IC 211635 under ICR 201405-0945-002 · OMB 0945-0007.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0945-0007 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Survey 03 13 2015.pdf	Other-survey

IC Title:

Questionnaire - Covered Entity Administrator or Privacy Officer(s)

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
Other-survey			Survey 03 13 2015.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 500

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	250	250
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.