Information Collection

Other Eligible Entity Attestation

IC 245415 under ICR 202101-0915-002 · OMB 0915-0126.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0126 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 44 Other Eligible Entity Attestation	Form and Instruction
44 Other Eligible Entity Attestation_0915-0126.pdf Other Eligible Entity Attestation_0915-0126.pdf	Form and Instruction
44 Other Eligible Entity Attestation_0915-0126.pdf Other Eligible Entity Attestation_0915-0126.pdf	Form and Instruction

IC Title:

Other Eligible Entity Attestation

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	44	Other Eligible Entity Attestation_0915-0126.pdf	Other Eligible Entity Attestation_0915-0126.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,884

Number of Respondents for Small Entity: 100

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,884	1,884
Annual IC Time Burden (Hours)	1,884	1,884
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.