Information Collection

Request for Point of Contact at Health Care Facility

IC 215333 under ICR 201502-0920-016 · OMB 0920-1075.

Documents and Forms

Document Name Document Type
Appendix G_HD Request for HC POC_Final.docx Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Request for Point of Contact at Health Care Facility	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
Instruction			Appendix G_HD Request for HC POC_Final.docx	None	No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 15	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	15	15
Annual IC Time Burden (Hours)	15	15
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.