Information Collection

Att 7_Participant Enrollment Form

IC 231864 under ICR 201806-0920-009 · OMB 0920-1239.

Documents and Forms

Document Name Document Type
Form 0920 Att 7_Participant Enrollment Form Form
0920 Participant Enrollment Form Att 7 Participant Enrollment Form 17AUZ FINAL 051818.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Att 7_Participant Enrollment Form	Agency IC Tracking Number:	0920-17AUZ

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	0920	Participant Enrollment Form	Att 7 Participant Enrollment Form 17AUZ FINAL 051818.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: 09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems	FR Citation: 57 FR 62812

Number of Respondents: 1,000	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	1,000	1,000
Annual IC Time Burden (Hours)	583	583
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.