Information Collection

EHLR Privacy Act Opt Out Form

IC 261508 under ICR 202307-0923-001 · OMB 0923-0060.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0923-0060 EHLR Privacy Act Opt Out Form	Form and Instruction
0923-0060 EHLR Privacy Act Opt Out Form Att3b-EHLR Privacy Act Opt Out Form (Word) RSTw-Chg.docx	Form and Instruction
0923-0060 EHLR Privacy Act Opt Out Form Att3b-EHLR Privacy Act Opt Out Form (Word) RSTw-Chg.docx	Form and Instruction
Att3a-EHLR-SampConfReg (Imm) (screenshots) online RSTw-Chg.docx Sample Conference Registration Forms (Immersion) (screenshots)	IC Document
Att3a-EHLR-SampConfReg (Imm) (screenshots) online RSTw-Chg.docx Sample Conference Registration Forms (Immersion) (screenshots)	IC Document

IC Title:

Agency IC Tracking Number:

0923-0060

Is this a Common Form? No

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	0923-0060	EHLR Privacy Act Opt Out Form	Att3b-EHLR Privacy Act Opt Out Form (Word) RSTw-Chg.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Training and Employment

Privacy Act System of Records

Title: 09-20-0161 Records of Health Professional in Disease Prevention and Control Training Programs, HHS/CDC/NCPS

FR Citation: 83 FR 6591

Number of Respondents: 11

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	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	11	11	0
Annual IC Time Burden (Hours)	1	-9	10
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Sample Conference Registration Forms (Immersion) (screenshots)	Att3a-EHLR-SampConfReg (Imm) (screenshots) online RSTw-Chg.docx	08/09/2023

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