Information Collection

Pre-Assessment

IC 212226 under ICR 201410-0990-001 · OMB 0990-0422.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0990-0422 can be found here:

Documents and Forms

Document Name Document Type
0990-IPV_Pre-Assessment 6_26_2014.doc Other-survey

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Pre-Assessment	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
Other-survey			0990-IPV_Pre-Assessment 6_26_2014.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,600	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Previously Approved
Annual Number of Responses for this IC	1,600	1,600
Annual IC Time Burden (Hours)	667	667
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.