Information Collection

Pilot Test

IC 263752 under ICR 202311-3041-004 · OMB 3041-0201.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Example Proposed Instruments_2023.docx	Other-Agreement, Consent, Questionna
Example Proposed Instruments_2023.docx	Other-Agreement, Consent, Questionna

IC Title:

Pilot Test

Agency IC Tracking Number:

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
Other-Agreement, Consent, Questionnaire, and other instruments			Example Proposed Instruments_2023.docx		No		Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4

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	4	4
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.