Information Collection

Enrollment Questionnaire for Clinics and Shelter

IC 225035 under ICR 201903-0920-008 · OMB 0920-1170.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1170 Site Enrollment Questionnaire Enrollment Questionnaire for Clinics and Shelter	Form and Instruction
Form 0920-1170 Site Enrollment Quesionnaire Spanish Enrollment Questionnaire for Clinics and Shelter	Form and Instruction
0920-1170 Site Enrollment Questionnaire Att C - Site Enrollment Questionnaire ENGLISH.docx	Form and Instruction
0920-1170 Site Enrollment Quesionnaire Spanish Att C - Site Enrollment Questionnaire SPANISH.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

16BGH

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	0920-1170				No		Fillable Fileable
Form and Instruction	0920-1170				No		Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 26

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	26	26
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.

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