Information Collection

Self-Query on an Individual

IC 206498 under ICR 202310-0915-003 · OMB 0915-0126.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 19 Self-Query on an Individual	Form and Instruction
19 Self-Query on an Individual.pdf Self-Query on an Individual.pdf	Form and Instruction
19 Self-Query on an Individual.pdf Self-Query on an Individual.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	19	Self-Query on an Individual.pdf	Self-Query on an Individual.pdf		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: 223,589

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	Previously Approved
Annual Number of Responses for this IC	223,589	55,032	168,557
Annual IC Time Burden (Hours)	93,907	23,113	70,794
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.