Information Collection

State Licensing Board Attestation

IC 206507 under ICR 202310-0915-003 · OMB 0915-0126.

Documents and Forms

Document Name Document Type
Form 28 State Licensing Board Attestation Form and Instruction
28 State Licensing Board Attestation.pdf State Licensing Board Attestation.pdf Form and Instruction
28 State Licensing Board Attestation.pdf State Licensing Board Attestation.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	State Licensing Board Attestation	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	28	State Licensing Board Attestation.pdf	State Licensing Board Attestation.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: 360	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	360	35	325
Annual IC Time Burden (Hours)	360	35	325
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.