CoC Applicants - State/local

Electronic Application for NIH Certificates of Confidentialty (CoC E-application System)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0689 can be found here:

Documents and Forms

Document Name Document Type
Form 1 CoC Applicants - State/local Form and Instruction
1 NIH Certificates of Confidentiality Request Form Screens CoC v3_with burden disclosure revised with changes highlighted 030320.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	CoC Applicants - State/local	Agency IC Tracking Number:

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	1	NIH Certificates of Confidentiality Request Form Screenshots	CoC v3_with burden disclosure revised with changes highlighted 030320.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: NIH Privacy Act Systems of Record 09-25-0156, “Records of Participants in Programs and Respondents in Surveys Used to Evaluate Programs of the Public Health Service, HHS/PHS/NIH/OD	FR Citation: 67 FR 60742

Number of Respondents: 26	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	26	26
Annual IC Time Burden (Hours)	39	39
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.