Information Collection

Contact Form

IC 232933 under ICR 201808-0920-015 · OMB 0920-1245.

Documents and Forms

Document Name Document Type
Contact Form Form and Instruction
PrEP Project Contact Form Att 3f Project Contact Form.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Contact Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	NA	PrEP Project Contact Form	Att 3f Project Contact Form.docx	NA	No		Paper Only

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: 300	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	300	300
Annual IC Time Burden (Hours)	5	5
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.