Information Collection

Federal Government Initial Request - Web Screenshot

IC 212166 under ICR 201710-0925-001 · OMB 0925-0703.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0703 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Federal Government Initial Request - Web Screenshot	Form and Instruction
1 Initial/Annual Request Resource Requirement A2_Initial-Annual Resource Requirment Request -Screenshots.doc	Form and Instruction

IC Title:

Federal Government Initial Request - Web Screenshot

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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	1	Initial/Annual Request Resource Requirement	A2_Initial-Annual Resource Requirment Request -Screenshots.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 60

Number of Respondents for Small Entity: 0

Affected Public: Federal Government

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-60	60
Annual IC Time Burden (Hours)	-30	30
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.