Information Collection

NEARS Data Recording Form

IC 221095 under ICR 201604-0920-009 · OMB 0920-0980.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0980 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
NEARS Data Recording Form	Form and Instruction
NEARS Data Recording Instrument Att6 -DataRcrdingInstrmnt.docx	Form and Instruction

IC Title:

NEARS Data Recording Form

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 and Instruction	NA	NEARS Data Recording Instrument	Att6 -DataRcrdingInstrmnt.docx	NA	No		Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 250

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	250	250
Annual IC Time Burden (Hours)	125	125
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.