Information Collection

Health Disparities Research Institute (HDRI) (NIMHD)

IC 256759 under ICR 202210-0925-007 · OMB 0925-0740.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0740 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Application Health Disparities Research Institute (HDRI) (NIMHD)	Form and Instruction
1 Application Final 2023 HDRI Application Form (11-2-22).docx	Form and Instruction
sub-study template 2023HD_1.docx sub-study or HDRI application	IC Document
Privacy Act Memo NIMHDH_1.PDF Privacy Act Memo	IC Document
PIA NIMHDG_1.PDF PIA	IC Document

IC Title:

Health Disparities Research Institute (HDRI) (NIMHD)

Agency IC Tracking Number:

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				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 250

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	250	250
Annual IC Time Burden (Hours)	104	104
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
sub-study or HDRI application		11/04/2022
Privacy Act Memo		11/04/2022
PIA		11/04/2022

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

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