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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.