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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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:

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

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 %

	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

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.