Information Collection

Participant Information Form

IC 195092 under ICR 201303-0920-009 · OMB 0920-0017.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0017 can be found here:

Documents and Forms

Document Name Document Type
Participant Information Form Form
Participant Information Form Proposed PIF Form 2011 OMB.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Participant Information Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Participant Information Form	Proposed PIF Form 2011 OMB.docx		Yes	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 8,975	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-8,975	8,975
Annual IC Time Burden (Hours)	-748	748
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.