Information Collection

Certification of Compliance with 42 U.S.C. § 282(j)(5)(B)

IC 258995 under ICR 202505-0910-007 · OMB 0910-0332.

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Information Collection (IC) Details

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IC Title:	Certification of Compliance with 42 U.S.C. § 282(j)(5)(B)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 11

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

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: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	4	4
Annual IC Time Burden (Hours)	3	3
Annual IC Cost Burden (Dollars)	0	0

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