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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.