Information Collection

EQUIP Enrollment Form

IC 255946 under ICR 202602-0920-004 · OMB 0920-1389.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
EQUIP Enrollment Form EQUIP Enrollment Form	Form
EQUIP Enrollment Form Att 3k EQUIP_Enrollment_Form_web_508_FINAL.pdf	Form

IC Title:

Agency IC Tracking Number:

0920-1389

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	n/a				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 240

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	240	240
Annual IC Time Burden (Hours)	40	40
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.

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