Information Collection

416-9

IC 7244 under ICR 200909-0925-002 · OMB 0925-0002.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0002 can be found here:

Documents and Forms

Document Name Document Type
Form 4 416-9 Form
phs416-9.docm Instruction
1 Form 416-1cont.docm Form
2 Form 416-9 fp1.docm Form
3 Form 416-9 fp3.docm Form
4 Report 416-9-Inclusion enrollment_report.docm Form
4 Table 416-9-Targeted_Planned enrollment_table.docm Form
2 Form 416-9 fp2.doc Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	416-9	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	4	Report	416-9-Inclusion enrollment_report.docm	Yes	Yes	Paper Only
Form	4	Table	416-9-Targeted_Planned enrollment_table.docm	Yes	Yes	Paper Only
Form	2	Form	416-9 fp2.doc	Yes	Yes	Paper Only
Instruction			phs416-9.docm	Yes	Yes	Paper Only
Form	1	Form	416-1cont.docm	Yes	Yes	Paper Only
Form	2	Form	416-9 fp1.docm	Yes	Yes	Paper Only
Form	3	Form	416-9 fp3.docm	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,832	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	1,832	1,832
Annual IC Time Burden (Hours)	27,480	27,480
Annual IC Cost Burden (Dollars)	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.