Information Collection

One Time Query for an Individual

IC 206496 under ICR 202310-0915-003 · OMB 0915-0126.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 17 One Time Query for an Individual	Form and Instruction
Form 17 One-Time Query for an Individual.pdf One Time Query for an Individual	Form and Instruction
17 One-Time Query for an Individual.pdf One-Time Query for an Individual.pdf	Form and Instruction
17 One-Time Query for an Individual.pdf One-Time Query for an Individual.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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	17				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title: System of Record Notice 09-15-0054

FR Citation: 88 FR 17854

Number of Respondents: 5,735,715

Number of Respondents for Small Entity: 35,000

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	5,735,715	427,761	5,307,954
Annual IC Time Burden (Hours)	144,413	-13,246	157,659
Annual IC Cost Burden (Dollars)	0	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.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].