Information Collection

Aim 2a Cohort HIPAA Form (English & Spanish)

IC 263122 under ICR 202309-0920-011 · OMB 0920-1423.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1423 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-22GA Aim 2a Cohort HIPAA Form (English & Spanish)	Form and Instruction
0920-22GA Att 4h_Aim2aCohortHIPAAFormEnglish Att_4h_Aim2aCohortHIPAAFormEnglish[1].docx	Form and Instruction
0920-22GA Att 4h_Aim2aCohortHIPAAFormEnglish Att_4h_Aim2aCohortHIPAAFormEnglish[1].docx	Form and Instruction
0920-22GA Att 4h_Aim2aCohortHIPAAFormSpanish Att_4h_Aim2aCohortHIPAAFormSpanish[1].docx	Form and Instruction
0920-22GA Att 4h_Aim2aCohortHIPAAFormSpanish Att_4h_Aim2aCohortHIPAAFormSpanish[1].docx	Form and Instruction

IC Title:

Aim 2a Cohort HIPAA Form (English & Spanish)

Agency IC Tracking Number:

0920-22GA

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	0920-22GA	Att 4h_Aim2aCohortHIPAAFormEnglish	Att_4h_Aim2aCohortHIPAAFormEnglish[1].docx		Yes	Yes	Fillable Fileable
Form and Instruction	0920-22GA	Att 4h_Aim2aCohortHIPAAFormSpanish	Att_4h_Aim2aCohortHIPAAFormSpanish[1].docx		Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Training and Employment

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 134

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	134	134
Annual IC Time Burden (Hours)	11	11
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.