Information Collection

EIP or State Health Dept Employee

IC 241587 under ICR 202009-0920-021 · OMB 0920-1296.

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.