Information Collection

Data Submission

IC 201035 under ICR 202109-0935-002 · OMB 0935-0195.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0195 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form #4 Data Submission	Form and Instruction
Form #4 NH Welcome and Login Pages Attachment D - Nursing Home Data Submission Emails.docx	Form and Instruction
Form #4 NH Welcome and Login Pages Attachment D - Nursing Home Data Submission Emails.docx	Form and Instruction
Attachment K - NH Submission Home Page.docx Attachment K - NH Submission Home Page	IC Document
Attachment K - NH Submission Home Page.docx Attachment K - NH Submission Home Page	IC Document
Attachment I - Emails - NH SOPS Data Submission.doc Attachment I - Emails - NH SOPS Data Submission	IC Document
Attachment I - Emails - NH SOPS Data Submission.doc Attachment I - Emails - NH SOPS Data Submission	IC Document
Attachment L - NH Questionnaire Upload Page.docx Attachment L - NH Questionnaire Upload Page	IC Document
Attachment L - NH Questionnaire Upload Page.docx Attachment L - NH Questionnaire Upload Page	IC Document
Attachment M - NH SOPS Data Submission Specs.pdf Attachment M - NH SOPS Data Submission Specs	IC Document
Attachment M - NH SOPS Data Submission Specs.pdf Attachment M - NH SOPS Data Submission Specs	IC Document

IC Title:

Data Submission

Agency IC Tracking Number:

Is this a Common Form? No

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 and Instruction	Form #4	NH Welcome and Login Pages	Attachment D - Nursing Home Data Submission Emails.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 40

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	40	-20	60
Annual IC Time Burden (Hours)	40	-20	60
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment K - NH Submission Home Page	Attachment K - NH Submission Home Page.docx	01/31/2012
Attachment I - Emails - NH SOPS Data Submission	Attachment I - Emails - NH SOPS Data Submission.doc	01/31/2012
Attachment L - NH Questionnaire Upload Page	Attachment L - NH Questionnaire Upload Page.docx	01/31/2012
Attachment M - NH SOPS Data Submission Specs	Attachment M - NH SOPS Data Submission Specs.pdf	01/31/2012

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.