Information Collection

Att 3A_NPIN Questionnaire _ New Organization

IC 223251 under ICR 201608-0920-014 · OMB 0920-0255.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.