Information Collection

EM provider renewal, change to plan and EM certification

IC 223370 under ICR 201609-0648-001 · OMB 0648-0745.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
EM provider renewal, change to plan and EM certification	Form and Instruction
EM System Certification Form EM System Certification Form.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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	EM System Certification Form	EM System Certification Form.docx		Yes	No	Fillable Printable

Line of Business: Natural Resources

Subfunction: Conservation, Marine and Land Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5

Number of Respondents for Small Entity: 2

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	70	70
Annual IC Time Burden (Hours)	25	25
Annual IC Cost Burden (Dollars)	33	33

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.