Information Collection

Laboratory Results Form

IC 216625 under ICR 201505-0920-002 · OMB 0920-1064.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Laboratory Results Form	Form
Laboratory Results Form Att7_LaboratoryResultsForm 20150518 clean.docx	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	None	Laboratory Results Form	Att7_LaboratoryResultsForm 20150518 clean.docx	None	No		Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,250	4,250
Annual IC Time Burden (Hours)	708	708
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.