Information Collection

Subject Statement and Dispute

IC 206501 under ICR 201611-0915-002 · OMB 0915-0126.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0126 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 22 Subject Statement and Dispute	Form and Instruction
22 Subject Statement and Dispute 22 SubjectStatementDispute.pdf	Form and Instruction

IC Title:

Subject Statement and Dispute

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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	22	Subject Statement and Dispute	22 SubjectStatementDispute.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,501

Number of Respondents for Small Entity: 3,500

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	3,501	3,501
Annual IC Time Burden (Hours)	2,626	2,626
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.