Application Form

Million Hearts Hypertension Control Challenge

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0976 can be found here:

Documents and Forms

Document Name Document Type
Application Form Form and Instruction
Att 3 Revised Application Form track changes_08072017.docx Other-This is a reference document t
Application Form Att 3 Revised Application Form clean_08072017.docx Form and Instruction
Attachment 3d Confirmation email 0920-0976.docx Confirmation Email IC Document
Attachment 6 Screenshots 2016 Challenge 0920-0976.pdf Screenshots of Updated 2016 Web site IC Document

Information Collection (IC) Details

IC Title:	Application Form	Agency IC Tracking Number:	0920-17AYF

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 and Instruction	n/a	Application Form	Att 3 Revised Application Form clean_08072017.docx		Yes	Yes	Fillable Fileable
Other-This is a reference document that shows changes in track-changes format.			Att 3 Revised Application Form track changes_08072017.docx		No		Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 500	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: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	250	250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Confirmation Email	Attachment 3d Confirmation email 0920-0976.docx	09/19/2016
Screenshots of Updated 2016 Web site	Attachment 6 Screenshots 2016 Challenge 0920-0976.pdf	09/19/2016

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.