Information Collection

Att 3_Health Professional Application for Training (HPAT)

IC 217674 under ICR 201507-0920-014 · OMB 0920-1099.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1099 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att 3 HPAT-wordversion.docx	Other-WORD
Att 4 HPAT-screenshot.pdf	Other-SCREENSHOTS

IC Title:

Att 3_Health Professional Application for Training (HPAT)

Agency IC Tracking Number:

16NR

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
Other-WORD			Att 3 HPAT-wordversion.docx		Yes	Yes	Fillable Printable
Other-SCREENSHOTS			Att 4 HPAT-screenshot.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,400

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	14,800	14,800
Annual IC Time Burden (Hours)	1,233	1,233
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.