Information Collection

Health Department Roster Form

IC 225218 under ICR 201701-0920-003 · OMB 0920-1187.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1187 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Health Department Roster Form	Form and Instruction
Health Department Roster Form Attachment 3. Health Department Roster.xlsx	Form and Instruction

IC Title:

Health Department Roster Form

Agency IC Tracking Number:

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 and Instruction	NA	Health Department Roster Form	Attachment 3. Health Department Roster.xlsx	NA	Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Training and Employment

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,231

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	3,231	3,231
Annual IC Time Burden (Hours)	269	269
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.