Information Collection

Additional Documentation and Certification

IC 208417 under ICR 202603-0915-003 · OMB 0915-0334.

Documents and Forms

Document Name Document Type
Form 3 Certification Form Additional Documentation and Certification Form
Form 3 Certification Form Additional Documentation and Certification Form
3 Certification Form Certification Form.docx Form
3 Certification Form Certification Form.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Additional Documentation and Certification	Agency IC Tracking Number:

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	3	Certification Form	Certification Form.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title: CICP System of Records Notice	FR Citation: 84 FR 28829

Number of Respondents: 324	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 80 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	324	294	30
Annual IC Time Burden (Hours)	243	220	23
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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