Information Collection

Application Form

IC 206920 under ICR 202601-0920-005 · OMB 0920-0976.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0976 Application Form	Form
Form 0920-0976 Application Form Application Form	Form
0920-0976 Application Form Attachment 3a. MH Hypertension Control Challenge Application_12.11.25.docx	Form
0920-0976 Application Form Attachment 3a. MH Hypertension Control Challenge Application_12.11.25.docx	Form
Attachment 3b. Confirmation email 0920-0976.docx Confirmation Email	IC Document
Attachment 3b. Confirmation email 0920-0976.docx Confirmation Email	IC Document
Attachment 6 Screenshot of application.pdf Screenshots of Updated 2016 Web site	IC Document
Attachment 6 Screenshot of application.pdf Screenshots of Updated 2016 Web site	IC Document
Attachment 3b. Confirmation email 0920-0976.docx Confirmation Email	IC Document
Attachment 3b. Confirmation email 0920-0976.docx Confirmation Email	IC Document
Attachment 6. Screenshot of Champions Application_2025.jpeg Screenshot of Champions	IC Document
Attachment 6. Screenshot of Champions Application_2025.jpeg Screenshot of Champions	IC Document

IC Title:

Application Form

Agency IC Tracking Number:

0920-0976

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	0920-0976				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

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	100	-100	200
Annual IC Time Burden (Hours)	50	-50	100
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Confirmation Email		09/29/2022
Screenshots of Updated 2016 Web site		09/29/2022
Confirmation Email		01/29/2026
Screenshot of Champions		01/29/2026

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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