Information Collection

Input Patient Data and Test Result Reporting - Long Term Program

IC 246540 under ICR 202103-0920-012 · OMB 0920-1336.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Input Patient Data and Test Result Reporting - Long Term Program	Form
SimpleReport Mobile Application SimpleReport Screenshot.PNG	Form
SimpleReport Mobile Application SimpleReport Screenshot.PNG	Form

IC Title:

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	NA	SimpleReport Mobile Application	SimpleReport Screenshot.PNG	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 250,000

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	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	250,000	250,000
Annual IC Time Burden (Hours)	25,000	25,000
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.