Information Collection

NSQAP Enrollment Form (Domestic)

IC 255951 under ICR 202602-0920-004 · OMB 0920-1389.

Documents and Forms

Document Name Document Type
NSQAP Enrollment Form NSQAP Enrollment Form (Domestic) Form
NSQAP Enrollment Form Att 3m NSQAP Enrollment Form.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	NSQAP Enrollment Form (Domestic)	Agency IC Tracking Number:	0920-1389

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	n/a	NSQAP Enrollment Form	Att 3m NSQAP Enrollment Form.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	3	-68	71
Annual IC Time Burden (Hours)	1	-11	12
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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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