Information Collection

Additional Documentation and Certification

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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Agency IC Tracking Number:

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	3				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 %

table that charts list of burden
	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

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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