Information Collection

Rachel Pearline Award Nomination Form (NCI)

IC 271248 under ICR 202307-0925-004 · OMB 0925-0766.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0766 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Nomination Form Rachel Pearline Award Nomination Form (NCI)	Form
1 Nomination Form 2025 Rachel Pearline Award Nomination Form.pdf	Form
Sub-Study - Pearline.docx Template	IC Document
Pearline Award_Sample Email for OMB.docx Email Correspondence	IC Document

IC Title:

Rachel Pearline Award Nomination Form (NCI)

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	1				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Records of Participants in Programs and Respondents in Surveys Used to Evaluate Programs of the Public Health Service

FR Citation: 88 FR 49473

Number of Respondents: 15

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	15	15
Annual IC Time Burden (Hours)	8	8
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Template		09/27/2024
Email Correspondence		09/27/2024

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

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