Information Collection

Set-up Fee Questionnaire (2023-2025)

IC 256557 under ICR 202210-0920-012 · OMB 0920-0234.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0234 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-0234 Set-up Fee Questionnaire (2023-2025) Form and Instruction
0920-0234 Attachment J_Set-up Fee Questionnaire Attachment J_Set-up Fee Questionnaire.pdf Form and Instruction
0920-0234 Attachment J_Set-up Fee Questionnaire Attachment J_Set-up Fee Questionnaire.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Set-up Fee Questionnaire (2023-2025)	Agency IC Tracking Number:	0920-0234

Is this a Common Form? Yes		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	0920-0234	Attachment J_Set-up Fee Questionnaire	Attachment J_Set-up Fee Questionnaire.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 200	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 %

	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	200	167	33
Annual IC Time Burden (Hours)	50	42	8
Annual IC Cost Burden (Dollars)	0	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.