Information Collection

Participant Form

IC 194189 under ICR 201701-0930-002 · OMB 0930-0288.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0288 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Participant Form - Participant Form	Form and Instruction
Participant Form - Participant Form - English Attachment 2 - Participant Form_English Version_10-13-16.doc	Form and Instruction
Participant Form - Participant Form - Spanish Attachment 3 - Participant Form_Spanish Version_10-13-16.doc	Form and Instruction
Attachment 6 - Invitation to a Communities Talk Event_10-13-16.doc Invitation	IC Document

IC Title:

Participant Form

Agency IC Tracking Number:

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 and Instruction	Participant Form - English	Participant Form - English	Attachment 2 - Participant Form_English Version_10-13-16.doc		Yes	Yes	Fillable Fileable
Form and Instruction	Participant Form - Spanish	Participant Form - Spanish	Attachment 3 - Participant Form_Spanish Version_10-13-16.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,500

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	4,500	4,500
Annual IC Time Burden (Hours)	374	374
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Invitation	Attachment 6 - Invitation to a Communities Talk Event_10-13-16.doc	01/19/2017

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