Information Collection

Panel Replenishment Baseline and Enrollment Survey

IC 216701 under ICR 202004-0910-008 · OMB 0910-0815.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment_3_Respondent_Materials_English_CLEAN_042220.pdf	Other-Respondent Materials - English
Attachment_4_Respondent_Materials_Spanish_CLEAN_042220.pdf	Other-Respondent Materials - Spanish

IC Title:

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
Other-Respondent Materials - English			Attachment_3_Respondent_Materials_English_CLEAN_042220.pdf		No		Printable Only
Other-Respondent Materials - Spanish			Attachment_4_Respondent_Materials_Spanish_CLEAN_042220.pdf		No		Printable Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	1,650	1,650
Annual IC Time Burden (Hours)	826	826
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.