Information Collection

Application Form

IC 206920 under ICR 201907-0920-008 · OMB 0920-0976.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0976 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0976 Application Form	Form and Instruction
0920-0976 Application Form Attachment 3a. Revised Application Form 0920-0976.docx	Form and Instruction
Attachment 3b. Confirmation email 0920-0976.docx Confirmation Email	IC Document
Attachment 6 Screenshot 2019 Challenge 0920-0976.pdf Screenshots of Updated 2016 Web site	IC Document

IC Title:

Application Form

Agency IC Tracking Number:

0920-0976

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	0920-0976	Application Form	Attachment 3a. Revised Application Form 0920-0976.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 200

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: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	200	-300	500
Annual IC Time Burden (Hours)	100	-150	250
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Confirmation Email	Attachment 3b. Confirmation email 0920-0976.docx	07/25/2019
Screenshots of Updated 2016 Web site	Attachment 6 Screenshot 2019 Challenge 0920-0976.pdf	07/25/2019

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.