Information Collection

Enrollment Questionnaire for Clinics and Shelter

IC 225035 under ICR 201701-0920-002 · OMB 0920-1170.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1170 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Enrollment Questionnaire for Clinics and Shelter	Form
Enrollment Questionnaire Att C--Site_Enrollment_Questionnaire_2016_9_22.docx	Form
Enrollment Questionnaire - Spanish Att C--Site_Enrollment_Questionnaire_2016_12_19_Spanish.docx	Form

IC Title:

Enrollment Questionnaire for Clinics and Shelter

Agency IC Tracking Number:

16BGH

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	none	Enrollment Questionnaire - Spanish	Att C--Site_Enrollment_Questionnaire_2016_12_19_Spanish.docx		No		Paper Only
Form	none	Enrollment Questionnaire	Att C--Site_Enrollment_Questionnaire_2016_9_22.docx		No		Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 26

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	26	26
Annual IC Time Burden (Hours)	2	2
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.