Information Collection

Spanish Contact Information Form

IC 220012 under ICR 201803-0920-008 · OMB 0920-1122.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1122 Spanish Contact Information Form	Form
0920-1122 Spanish Contact information Form (CH STRONG) Att. 19 - Spanish Contact Info Form (CH STRONG).docx	Form

IC Title:

Agency IC Tracking Number:

0920-1122

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	0920-1122	Spanish Contact information Form (CH STRONG)	Att. 19 - Spanish Contact Info Form (CH STRONG).docx		No		Printable Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Epidemiological Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 42

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	42	42
Annual IC Time Burden (Hours)	2	2
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.