Information Collection

Medium Assessment

IC 243645 under ICR 202105-0750-001 · OMB 0750-0004.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0750-0004 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
0750-0004 Collection Instruments 252.204-7019 and 252.204-7020.docx	Other-Clauses
0750-0004 Collection Instruments 252.204-7019 and 252.204-7020.docx	Other-Clauses

IC Title:

Medium Assessment

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 48 CFR 204 48 CFR 252

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-Clauses			0750-0004 Collection Instruments 252.204-7019 and 252.204-7020.docx		Yes	Yes	Fillable Fileable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 200

Number of Respondents for Small Entity: 52

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	Previously Approved
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	1,600	1,600
Annual IC Cost Burden (Dollars)	181,712	181,712

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.