Information Collection

Nomination Form

IC 206920 under ICR 201609-0920-007 · OMB 0920-0976.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0976 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Attachment 3b Nomination Form	Form
Attachment 3b Nomination Form Attachment 3b Revised Nomination Form 2016 Challenge 0920-0976.docm	Form
Attachment 3d Confirmation email 0920-0976.docx Confirmation Email	IC Document
Attachment 6 Screenshots 2016 Challenge 0920-0976.pdf Screenshots of Updated 2016 Web site	IC Document

IC Title:

Nomination Form

Agency IC Tracking Number:

15QG

Is this a Common Form? No

IC Status: Modified

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	Attachment 3b	Nomination Form	Attachment 3b Revised Nomination Form 2016 Challenge 0920-0976.docm		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 500

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, 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	500	500
Annual IC Time Burden (Hours)	250	250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Confirmation Email	Attachment 3d Confirmation email 0920-0976.docx	09/19/2016
Screenshots of Updated 2016 Web site	Attachment 6 Screenshots 2016 Challenge 0920-0976.pdf	09/19/2016

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