Information Collection

Program Facilitators- Fidelity log

IC 248508 under ICR 202107-0990-002 · OMB 0990-0480.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0990-0480 can be found here:

Documents and Forms

Document Name Document Type
Instrument 4_Fidelity Log832021.docx Other-instruction and log
Instrument 4_Fidelity Log832021.docx Other-instruction and log

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Program Facilitators- Fidelity log	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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
Other-instruction and log			Instrument 4_Fidelity Log832021.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 13	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	312	312
Annual IC Time Burden (Hours)	52	52
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.