Inclusion Enrollment Form

DoD Usage of Inclusion Enrollment Report Form

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0770 can be found here:

Documents and Forms

Document Name Document Type
1 inclusion enrollment Attachment 2 Inclusion Enrollment Report.pdf Form

Information Collection (IC) Details

IC Title:	Inclusion Enrollment Form	Agency IC Tracking Number:

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
Form	1	inclusion enrollment	Attachment 2 Inclusion Enrollment Report.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Extramural Awards and Chartered Advisory Committees (IMPAC 2), Contract Information (DCIS), and Cooperative Agreement Information	FR Citation: 67 FR 60742

Number of Respondents: 2,100	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	2,100	2,100
Annual IC Time Burden (Hours)	2,100	2,100
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.