Information Collection

Supplemental Investigator Data Form (Attachment 4)

IC 219968 under ICR 201602-0925-006 · OMB 0925-0613.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0613 can be found here:

Documents and Forms

Document Name Document Type
Form 3 Supplemental Investigator Data Form (Attachment 4) Form and Instruction
3 Attach 4 Supplemental Investigator data form Attach_4 Supplemental_investigator_data_form_final.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Supplemental Investigator Data Form (Attachment 4)	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
Form and Instruction	3	Attach 4 Supplemental Investigator data form	Attach_4 Supplemental_investigator_data_form_final.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: 09-25-0200	FR Citation: 67 FR 60776

Number of Respondents: 22,283	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	22,283	22,283
Annual IC Time Burden (Hours)	3,714	3,714
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.