Information Collection

Application Form

IC 206920 under ICR 201708-0920-007 · OMB 0920-0976.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0976 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Application Form	Form and Instruction
Att 3 Revised Application Form track changes_08072017.docx	Other-This is a reference document t
Application Form Att 3 Revised Application Form clean_08072017.docx	Form and Instruction
Attachment 3d Confirmation email 0920-0976.docx Confirmation Email	IC Document
Attachment 6 Screenshots 2016 Challenge 0920-0976.pdf Screenshots of Updated 2016 Web site	IC Document

IC Title:

Application Form

Agency IC Tracking Number:

0920-17AYF

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	n/a	Application Form	Att 3 Revised Application Form clean_08072017.docx		Yes	Yes	Fillable Fileable
Other-This is a reference document that shows changes in track-changes format.			Att 3 Revised Application Form track changes_08072017.docx		No		Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 500

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	250	250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Confirmation Email	Attachment 3d Confirmation email 0920-0976.docx	09/19/2016
Screenshots of Updated 2016 Web site	Attachment 6 Screenshots 2016 Challenge 0920-0976.pdf	09/19/2016

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