Information Collection

Pilot Test

IC 263752 under ICR 202311-3041-004 · OMB 3041-0201.

Documents and Forms

Document Name Document Type
Example Proposed Instruments_2023.docx Other-Agreement, Consent, Questionna
Example Proposed Instruments_2023.docx Other-Agreement, Consent, Questionna

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Pilot Test	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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
Other-Agreement, Consent, Questionnaire, and other instruments			Example Proposed Instruments_2023.docx		No		Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4	4
Annual IC Time Burden (Hours)	11	11
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.