Information Collection

Attachment 3 Data Submission Agreement

IC 213648 under ICR 201410-0925-006 · OMB 0925-0709.

Documents and Forms

Document Name Document Type
Form 1 Attachment 3 Data Submission Agreement Form and Instruction
1 Blank DoCTRS data submission agreement Blank_DoCTRS_data_submission_agreement.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Attachment 3 Data Submission Agreement	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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 and Instruction	1	Blank DoCTRS data submission agreement	Blank_DoCTRS_data_submission_agreement.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 12	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	12	12
Annual IC Time Burden (Hours)	60	60
Annual IC Cost Burden (Dollars)	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.