Information Collection

Subject Statement and Dispute

IC 206501 under ICR 202401-0906-003 · OMB 0906-0081.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 22 Subject Statement and Dispute	Form and Instruction
22 Subject Statement and Dispute.pdf Subject Statement and Dispute.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	22	Subject Statement and Dispute.pdf	Subject Statement and Dispute.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: 4,015

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	4,015	751	3,264
Annual IC Time Burden (Hours)	3,011	563	2,448
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.