Information Collection

Data Verification Form

IC 206921 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⚠️ Notice: This information collection may be referencing outdated material.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
Data Verification Form	Form and Instruction
Att 4 Revised Data Verification Form track changes_08072017.docm	Other-This is a reference document t
Revised Data Verification Form_08072017 Att 4 Revised Data Verification Form clean_08072017.docm	Form and Instruction

IC Title:

Data Verification 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	n/a	Revised Data Verification Form_08072017	Att 4 Revised Data Verification Form clean_08072017.docm		Yes	Yes	Fillable Fileable
Other-This is a reference document that shows changes in track-changes format.			Att 4 Revised Data Verification Form track changes_08072017.docm		No		Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 40

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	40	40
Annual IC Time Burden (Hours)	40	40
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.