Information Collection

Web-based Application Form

IC 212545 under ICR 201711-0925-004 · OMB 0925-0639.

Documents and Forms

Document Name Document Type
Form 1 Web-based Application Form Form and Instruction
1 Genetic Web-based Application Attachment 1 Genetic Web-based Application.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Web-based Application Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Genetic Web-based Application	Attachment 1 Genetic Web-based Application.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Records of Participants in Programs and Respondents in Surveys Used to Evaluate Programs of the Public Health Service	FR Citation: 67 FR 60742

Number of Respondents: 60	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
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

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.