Information Collection

Phs Supplements To Standard A-102 Forms

IC 165987 under ICR 197812-0937-004 · OMB 0937-0011.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0937-0011 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	PHS SUPPLEMENTS TO STANDARD A-102 FORMS	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?
Form	PHS 5159	No	No
Form	PHS 5161-1,2	No	No
Form	PHS 5162-1,2	No	No
Form	PHS 5163	No	No
Form	PHS 5164	No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,000	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	4,000	0	4,000
Annual IC Time Burden (Hours)	16,000	7,000	9,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded

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