Information Collection

Profile Completion

IC 249201 under ICR 202409-0925-003 · OMB 0925-0774.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Profile Completion	Form
1 Questionnaire Attachment 1 Profile Completion Questionaire 8.15.24_FINAL.docx	Form
1 Questionnaire Attachment 1 Profile Completion Questionaire 8.15.24_FINAL.docx	Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Profile Completion

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	1	Questionnaire	Attachment 1 Profile Completion Questionaire 8.15.24_FINAL.docx		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: 09-25-0156, âRecords of Participants in Programs and Respondents in Surveys Used to Evaluate Programs of the Public Health Service, HHS/PHS/NIH/ODâ

FR Citation: 67 FR 60742

Number of Respondents: 30

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	Previously Approved
Annual Number of Responses for this IC	30	30
Annual IC Time Burden (Hours)	15	15
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.