Information Collection

Profile Completion

IC 249201 under ICR 202109-0925-002 · OMB 0925-0774.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0774 can be found here:

2024-09-19 - Revision of a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Profile Completion	Form and Instruction
1 Profile Completion Questionnaire Attachment 1 Profile Completion Questionaire.docx	Form and Instruction
1 Profile Completion Questionnaire Attachment 1 Profile Completion Questionaire.docx	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Profile Completion

Agency IC Tracking Number:

Is this a Common Form? No

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 and Instruction	1	Profile Completion Questionnaire	Attachment 1 Profile Completion Questionaire.docx		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: 09-25-0156, âRecords of Participants in Programs and Respondents in Surveys Used to Evaluate Programs of the Public Health Service, HHS/PHS/NIH/ODâ

FR Citation: 67 FR 60742

Number of Respondents: 30

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	30	30
Annual IC Time Burden (Hours)	15	15
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.