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MN Clinic Visit Form
Biomonitoring of Great Lakes Populations Program
OMB: 0923-0044
IC ID: 201464
OMB.report
HHS/TSDR
OMB 0923-0044
ICR 201407-0923-001
IC 201464
( )
Documents and Forms
Document Name
Document Type
MN Clinic Visit Form
Form
MN Clinic Visit
Att5f_MN_ClncVstForm_20120131.docx
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
MN Clinic Visit Form
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Unchanged
Obligation to Respond:
Voluntary
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
none
MN Clinic Visit
Att5f_MN_ClncVstForm_20120131.docx
No
No
Paper Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Immunization Management
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:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
250
0
0
0
0
250
Annual IC Time Burden (Hours)
4
0
0
0
0
4
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
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.
