Att 3A_NPIN Questionnaire _ New Organization

Resources and Services Database of the National Prevention Information Network

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0255 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-0255 Att 3A_NPIN Questionnaire _ New Organization Form and Instruction
0920-0255 NPIN Questionnaire for New Organizations Att3A_NPIN Questionnaire_New Organizations.docx Form and Instruction
Att4_ScreenShots_NPIN Online Questionnaire.docx Att 4_Screen Shots of the NPIN Online Questionnaire IC Document
Att5_Sample_NPIN_res_serv_db_record.docx Att 5_Sample NPIN Resource Service DB Record IC Document

Information Collection (IC) Details

IC Title:	Att 3A_NPIN Questionnaire _ New Organization	Agency IC Tracking Number:	0920-0255

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	0920-0255	NPIN Questionnaire for New Organizations	Att3A_NPIN Questionnaire_New Organizations.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 400	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	400	400
Annual IC Time Burden (Hours)	100	100
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Att 4_Screen Shots of the NPIN Online Questionnaire	Att4_ScreenShots_NPIN Online Questionnaire.docx	08/29/2016
Att 5_Sample NPIN Resource Service DB Record	Att5_Sample_NPIN_res_serv_db_record.docx	08/29/2016

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.