Information Collection

EIP or State Health Dept Employee

IC 241587 under ICR 202007-0920-015 · OMB 0920-1296.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1296 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-20MZ EIP or State Health Dept Employee	Form and Instruction
0920-20MZ EIP or State Health Dept Employee EIP or State Health Department Employee (no form).docx	Form and Instruction

IC Title:

EIP or State Health Dept Employee

Agency IC Tracking Number:

0920-20MZ

Is this a Common Form? No

IC Status: Unchanged

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	0920-20MZ	EIP or State Health Dept Employee	EIP or State Health Department Employee (no form).docx		No		Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5

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	Previously Approved
Annual Number of Responses for this IC	120	120
Annual IC Time Burden (Hours)	10	10
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.