Information Collection

Program Facilitators- Fidelity log

IC 248508 under ICR 202201-0990-002 · OMB 0990-0480.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0990-0480 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Instrument 4_Fidelity Log832021.docx	Other-instruction and log
Instrument 4_Fidelity Log832021.docx	Other-instruction and log

IC Title:

Program Facilitators- Fidelity log

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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
Other-instruction and log			Instrument 4_Fidelity Log832021.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 13

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	312	312
Annual IC Time Burden (Hours)	52	52
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.