Information Collection

(CREW) 72-hour Food/Activity History Template (AGE cases)

IC 252602 under ICR 202603-0920-012 · OMB 0920-1260.

Documents and Forms

Document Name Document Type
Form 0920-26-0121 VSP_72-hrFoodActivityHistoryForm (CREW) 72-hour Food/Activity History Template (AGE cases) Form
0920-26-0121 VSP_72-hrFoodActivityHistoryForm Attachment 5c_VSP_72-hrFoodActivityHistoryForm.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	(CREW) 72-hour Food/Activity History Template (AGE cases)	Agency IC Tracking Number:	0920-26-0121

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	0920-26-0121				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 18,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	18,000	750	17,250
Annual IC Time Burden (Hours)	3,000	125	2,875
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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