Information Collection

NIEHS simplified data collection form

IC 234598 under ICR 202109-0925-001 · OMB 0925-0757.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0757 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2 NIEHS simplified data collection form	Form
2 NIEHS Simplified Form Attachment III NIEHS Simplified Data Collection Form 2021 (7).docx	Form
2 NIEHS Simplified Form Attachment III NIEHS Simplified Data Collection Form 2021 (7).docx	Form

IC Title:

NIEHS simplified data collection form

Agency IC Tracking Number:

Is this a Common Form? Yes

IC Status: Modified

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	2	NIEHS Simplified Form	Attachment III NIEHS Simplified Data Collection Form 2021 (7).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 240

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	Previously Approved
Annual Number of Responses for this IC	240	240
Annual IC Time Burden (Hours)	40	40
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.