Information Collection

Private Sector - Special Data Request

IC 214570 under ICR 201501-0920-011 · OMB 0920-1053.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1053 can be found here:

Documents and Forms

Document Name Document Type
Private Sector - Special Data Request Form
Special Data Request Att 4_Special Data Request.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Private Sector - Special Data Request	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Special Data Request	Att 4_Special Data Request.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 52	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	52	52
Annual IC Time Burden (Hours)	312	312
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.