Information Collection

Data Agreement

IC 201282 under ICR 201810-0935-001 · OMB 0935-0197.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2 Attachment B: Clinician and Group Database Data Use Agreement Data Agreement	Form and Instruction
2 Attachment B: Clinician and Group Database Data Use Agre Oct7_Attachment B Agreement.docx	Form and Instruction

IC Title:

Data Agreement

Agency IC Tracking Number:

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 and Instruction	2				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 86

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	86	-154	240
Annual IC Time Burden (Hours)	22	10	12
Annual IC Cost Burden (Dollars)	0	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.

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