Information Collection

Contact Information Form

IC 222428 under ICR 201606-0920-022 · OMB 0920-1140.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1140 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Contact Information Form	Form
Contact Information Form Att. G - Contact Information Form.docx	Form

IC Title:

Contact Information 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	NA	Contact Information Form	Att. G - Contact Information Form.docx	NA	No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0136 - Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 200

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	200	200
Annual IC Time Burden (Hours)	7	7
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.