Information Collection

Inclusion Enrollment Form

IC 249404 under ICR 202109-0702-001CF · OMB 0925-0770.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
1 inclusion enrollment Attachment 2 Inclusion Enrollment Report.pdf	Form

IC Title:

Inclusion Enrollment Form

Agency IC Tracking Number:

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	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 %

table that charts list of burden
	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

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.