Information Collection

Data Agreement

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

Documents and Forms

Document Name Document Type
Form 2 Data Agreement Form and Instruction
2 Attachment B: Clinician and Group Database Data Use Agre Oct7_Attachment B Agreement.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	2	Attachment B: Clinician and Group Database Data Use Agreement	Oct7_Attachment B Agreement.docx		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 %

	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

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.